Failure to Follow Two-Person Mechanical Lift Transfer Policy
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, dependence on renal dialysis, and dementia, who was assessed as severely cognitively impaired and dependent on staff for all activities of daily living including transfers, was transferred using a mechanical lift by only one nurse aide. The resident's care guide and facility policy both required two-person assistance for mechanical lift transfers. Despite this, the nurse aide performed the transfer alone after the resident complained of leg pain, believing she could transfer the resident more gently by herself. The transfer was completed without incident, but the nurse aide acknowledged she was aware of the policy requiring two staff members and did not request assistance. Staff interviews confirmed that the second nurse aide, who was assigned to the resident, did not assist with the transfer. Both the Assistant Director of Nursing and the Administrator confirmed that facility policy mandates two staff members for all mechanical lift transfers to ensure resident safety. The failure to follow this policy resulted in a deficiency related to providing adequate supervision and ensuring a safe environment free from accident hazards.