Failure to Provide Adequate Supervision and Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) used a Sara lift (sit-to-stand lift) alone to transfer a resident who required substantial assistance, despite facility policy requiring two trained staff for all mechanical lift transfers. The CNA did not wait for assistance, even though another CNA was present in the facility and had previously been asked to help. During the transfer, the resident began to resist, moved around, and attempted to remove their arms from the sling, resulting in the resident sliding out of the sling and ending up hanging from the lift with their legs twisted underneath them. The resident involved had a history of dementia, stroke, osteoporosis, an artificial knee joint, spondylosis, and muscle weakness. The resident's care plan indicated a need for one-person assistance for transfers, but interviews and staff statements revealed that the resident was actually a two-person assist and required a Hoyer lift for transfers. There was no documented update in the care plan to reflect this change in transfer status, and staff used both the Sara and Hoyer lifts interchangeably. The resident was cognitively intact but had a history of rejecting care and required substantial to maximal assistance for transfers and bathing. Following the incident, staff responded to the CNA's call for help and found the resident hanging from the lift with a twisted leg. The resident was assessed and later found to have an acute impacted fracture of the left distal femur, confirmed by x-ray. The resident was subsequently sent to the hospital, where they later passed away. Staff interviews confirmed that the CNA was aware of the two-person requirement and the resident's transfer status but did not follow protocol, and there was a lack of clear signage or consistent communication regarding the resident's transfer needs.