Failure to Use Two-Person Assist During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the safety of two residents who were dependent on staff for transfers and at risk for falls by not following its own policy requiring two staff members to assist with mechanical lift transfers. The facility's policy, revised in July 2017, clearly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift. Both residents involved had care plans and Minimum Data Set (MDS) assessments indicating they required two-person assistance for transfers due to conditions such as dementia, Parkinson's disease, and cognitive impairment, and were dependent on staff for activities of daily living. Direct observations and review of video footage provided by family members showed that staff did not consistently use two-person assistance during mechanical lift transfers. In one instance, after both CNAs initially prepared the resident for transfer, only one CNA operated the lift and moved the resident from the wheelchair to the bed, while the other CNA was not assisting and was instead gathering supplies. The resident was left unsupported and swung while suspended in the lift. A similar pattern was observed with another resident, where one CNA operated the lift and moved the resident while the other CNA sat in a chair and did not participate until the resident was being lowered into the wheelchair. Interviews with the involved CNAs and the Director of Nursing confirmed that facility policy requires two staff members for all mechanical lift transfers, with one person operating the controls and the other guiding the resident. The staff acknowledged that they did not follow this protocol during the observed transfers. These actions directly led to the deficiency, as the facility did not provide adequate supervision or follow established procedures to prevent accidents for residents at risk of falls.