Failure to Ensure Safe Transfer Practices with Electronic Lift
Penalty
Summary
The facility failed to ensure safe transfer practices with an electronic lift for two residents who required assistance. One resident expressed discomfort with the new electronic lift, stating it did not fit properly and that he hit his head on the bar during a transfer. The resident's care guide specified the use of a toileting sling and hoyer lift with two staff for transfers, along with cervical precautions, but did not indicate which brand or size of sling should be used. Staff interviews revealed a lack of clarity regarding sling assessments and appropriate equipment selection for the resident, and there was no documentation that the incident of the resident hitting his head had been reported or addressed. During direct observation, staff were seen transferring another resident with the new lift without following manufacturer safety instructions. The bed was in the highest position, and the resident's buttocks did not clear the mattress before being moved. Staff did not check that all sling loops were properly attached before moving the resident, and the lift's legs were not in the fully open position as required for stability. Both staff members involved in the transfer were unaware of the need to check loop placement, ensure the resident cleared the surface before moving, or that the lift legs should be fully open for safety. Further review showed that staff had not received training on the new lift since its purchase, and there was no evidence that management had addressed residents' concerns or reported incidents related to the lift. The instruction manual for the lift provided clear safety requirements that were not followed during observed transfers. The lack of training, unclear care instructions, and failure to follow manufacturer guidelines contributed to unsafe transfer practices and accident hazards for residents requiring lift assistance.