Failure to Ensure Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed transferring a resident using a mechanical lift without the required assistance of a second staff member. The resident involved had significant medical conditions, including macular degeneration, dementia, osteoporosis, arthropathy, abnormalities of gait and mobility, and muscle weakness. The resident was unable to speak, had severe cognitive impairment, and was dependent on staff for all care and transfers, as documented in her care plan and Minimum Data Set (MDS) assessment. The care plan specifically required the use of a mechanical lift with two staff members for all transfers. Despite facility policy and training that mandated two staff members for mechanical lift transfers, the CNA reported routinely performing these transfers alone. The administrator and director of nursing confirmed that staff were trained to use two-person assistance for mechanical lift transfers, and the manufacturer's instructions indicated that the facility was responsible for determining when two-assist transfers were necessary. The observation and staff interviews demonstrated non-compliance with both facility policy and the resident's care plan requirements.