Failure to Ensure Safe Mechanical Lift Transfers Resulting in Resident Death
Penalty
Summary
A facility staff member failed to properly transfer a resident using a mechanical lift, resulting in a fall that caused significant injuries and ultimately contributed to the resident's death. The resident required total assistance for transfers, as documented in the care plan, which specified the use of a Hoyer lift with two staff members present. Despite this, the staff member performed the transfer alone, and during the process, one of the sling straps became unhooked, causing the resident to fall to the floor. The resident sustained a subdural hematoma, a C2 cervical fracture, and a forehead laceration, and passed away three days later, with the fall listed as a contributing factor on the death certificate. Interviews and record reviews revealed that the staff member who performed the transfer had not received orientation or a return demonstration on the use of mechanical lifts. She reported that it was common practice at the facility for CNAs to use the lifts alone, and that new staff were trained to do so. Other staff members corroborated that using mechanical lifts without a second person was a routine practice, and that straps had previously come unhooked during transfers. The staff member acknowledged knowing that two people were required for safe use of the lift but did not follow this protocol at the time of the incident. Additional staff interviews confirmed that the improper use of the mechanical lift was a known issue, with some staff reporting that they had observed or participated in single-person transfers despite the care plan and facility policy requiring two staff members. The incident was identified as an Immediate Jeopardy situation due to the risk of serious harm, and the deficiency was cited under F689 for failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.