Failure to Follow Two-Person Mechanical Lift Protocol Due to Staffing Shortages
Penalty
Fine: $16,985
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that services were provided according to professional standards regarding the safe use of mechanical lifts for one of eight sampled residents. The resident's care plan specified total dependence on two staff members for transfers using a Hoyer full body mechanical lift. Interviews with staff revealed that, despite being trained to use two staff for mechanical lifts, staff members sometimes performed transfers alone due to staffing shortages. Staff acknowledged awareness of the requirement for two-person assistance but reported that single-person transfers occurred when only one CNA was available per hall, and that this practice was not consistent with their training or facility policy.