Failure to Ensure Safe Mechanical Lift Transfers Due to Inadequate Staffing
Penalty
Summary
The facility failed to administer care in a manner that ensured individualized and safe transfer procedures for a resident requiring total assistance. The resident's care plan specified the use of a Hoyer lift with two staff members for transfers but did not identify the appropriate sling size. On the date of the incident, the resident was found on the floor with significant bleeding after falling from a Hoyer lift. Documentation and interviews revealed that the transfer was performed by a single certified nurse assistant, contrary to the care plan and facility policy. Multiple staff interviews confirmed that it was common practice for certified nurse assistants to operate mechanical lifts independently, and that management was aware of this deviation from policy. Staff reported that this practice had been ongoing for over a year, largely due to reduced staffing levels following administrative decisions to decrease staff hours. The reduction in available staff made it difficult to consistently have two staff members present for mechanical lift transfers, directly contributing to the incident.