Failure to Ensure Staff Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nurse assistants received proper training and competency evaluation on the procedure and safety requirements for using mechanical lifts. Fifteen out of sixteen sampled staff members had not received this training, and documentation of mechanical lift competency was only available for one staff member. New staff reported that they did not receive any training from the Director of Nursing prior to working with residents and were instead oriented by other CNAs, who advised that mechanical lift transfers could be performed independently, contrary to standard safety protocols. Several staff members confirmed they had not completed mechanical lift competency evaluations prior to a resident fall incident, with some stating their last training was years ago during their initial certification. A review of records showed that only one staff member had documented mechanical lift training, and the facility could not provide evidence of training for the remaining licensed and certified nursing staff, including management staff with CNA certification. The deficiency was highlighted by an incident in which a resident fell from a mechanical lift, resulting in the resident being found on the floor with significant bleeding. The incident was staff-witnessed, and it was reported that the transfer was performed using a mechanical lift.