Failure to Use Mechanical Lift and Two-Person Assistance During Resident Transfer
Penalty
Summary
Staff failed to provide adequate supervision and assistance during a transfer for a resident with severe cognitive impairment, arthritis, dementia, depression, and spinal stenosis. According to the resident's care plan and the facility's Safe Resident Handling/Transfer Policy, the resident required a mechanical lift with two-person assistance for all transfers. However, video footage showed a single staff member transferring the resident manually using a 'bear hug' technique, without the required mechanical lift or a second staff member present. During the transfer, the resident expressed discomfort and pain, specifically mentioning back pain, while the staff member continued the transfer without seeking additional help. Interviews with facility staff, including a CNA, RN, DON, and the Administrator, confirmed that staff were aware of the resident's need for two-person mechanical lift transfers and that manual lifting was not appropriate for this resident. The DON and Administrator were not aware of the incident until it was brought to their attention. The failure to follow the resident's care plan and facility policy resulted in a transfer being performed in a manner inconsistent with established safety protocols.