Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member, contrary to facility policy and manufacturer guidelines. The CNA admitted to performing the transfer alone and not positioning the lift legs properly, which caused the lift to tilt and the bar to strike the resident's forehead. The CNA acknowledged being aware of the policy requiring two staff for lift transfers and had received multiple in-services on lift safety, but chose not to request help even though other staff were available. The incident resulted in the resident sustaining a significant laceration to the forehead, which required emergency medical evaluation and sutures. At the time of the incident, the resident was noted to have severe cognitive impairment due to Alzheimer's Disease and was unable to participate in her own care decisions. The resident was found by a registered nurse (RN) still attached to the lift, with active bleeding from the forehead, and was subsequently sent to the emergency room for further assessment and treatment, including a CT scan and pain management. Facility records confirmed that the CNA had attended multiple in-services on lift safety and had signed off on training related to the use of mechanical lifts and slings. Interviews with the RN, Director of Nursing (DON), and Administrator all confirmed that the facility's policy requires two staff members for mechanical lift transfers and that this policy was not followed, directly resulting in the resident's injury.