Failure to Use Mechanical Lift for Dependent Resident Transfer
Penalty
Summary
Facility staff failed to follow the established policy and physician orders regarding safe transfer methods for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including hemiplegia, hemiparesis, a history of falls, unsteadiness, dementia, and legal blindness, was care planned and ordered to be transferred using a mechanical Hoyer lift with an appropriate sling for all transfers. Despite these orders and the facility's Total Lift Transfer policy, two CNAs transferred the resident from a wheelchair to a bed using a gait belt instead of the required mechanical lift. During the transfer, the wheelchair was not locked, and the resident was lifted by the gait belt while their feet did not touch the floor, and they did not stand up as instructed. The resident exhibited discomfort, moaning, and yelling during the transfer. Interviews with staff, including CNAs, an LPN, and the interim DON, confirmed that staff were expected to follow transfer orders and care plans, and that the resident should have been transferred using the Hoyer lift at all times. The CNAs involved did not adhere to these expectations, resulting in a transfer that was not in accordance with the resident's care plan or physician orders. The Administrator and Regional Director of Operation also stated that staff were expected to follow appropriate transfer methods as ordered and care planned.