Failure to Follow Two-Person Mechanical Lift Transfer Protocol
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for transfers was not safely and properly transferred according to their care plan and physician orders. The resident, who had diagnoses including dementia, urinary retention, failure to thrive, and severe cognitive impairment, required a mechanical lift with assistance from two staff members for all transfers. However, on one occasion, the resident was transferred from a wheelchair to a bed using a mechanical lift by only one CNA, contrary to the established plan of care and facility policy. The resident's spouse was present during the transfer, which was described as uneventful, and there was no witnessed fall. Subsequently, the resident was found to have pain in the right wrist, and an X-ray was ordered. The facility's investigation concluded that the injury was not related to a fall but likely occurred when the resident struck the bed rail. Review of facility documentation, including the Minimum Data Set, physician orders, and the care plan, confirmed that the resident required two-person assistance for transfers with a mechanical lift. The facility's policy also specified that two persons are required for mechanical lift usage, which was not followed in this instance.