Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure the safe use of a Sara Steady lift for a resident with multiple complex medical conditions, including impaired cognition, hemiplegia, and a history of traumatic brain injury. The resident required dependent assistance for activities of daily living and had no documented intervention or physician's order for the use of a Sara Steady lift for transfers. Despite this, a CNA placed the resident in the Sara Steady lift and left the resident unattended while seeking help, contrary to manufacturer guidelines and facility policy. The manufacturer's guidelines for the Sara Steady lift explicitly state that a resident must never be left unattended in the device, as it is intended only for active, supervised transfers and not for unassisted seating or prolonged periods. Witness statements and facility investigation confirmed that the CNA left the resident alone in the lift for approximately four to five minutes. During this time, the resident was found slumped over the lift's bar, unresponsive, and with a bloody bowel movement. Staff responded, initiated CPR, and emergency services were called. The root cause analysis conducted by facility leadership determined that the incident resulted from the staff member not following protocol for the resident lift and a lack of supervision. The event led to the resident experiencing cardiac arrest and being transferred to the hospital, where the resident later expired. The deficiency was identified as a failure to provide adequate supervision and to ensure the area was free from accident hazards, specifically regarding the use of mechanical lifts.