Failure to Provide Adequate Assistance During Mechanical Lift Transfer
Penalty
Summary
The facility failed to provide adequate assistance to prevent a resident from sliding out of a mechanical lift. According to the facility's policy, two staff members are required for any transfer involving a sit-to-stand mechanical lift. A resident with severe cognitive impairment, who was totally dependent on staff for transfers, slipped out of the sit-to-stand mechanical lift and was assisted to the ground. The incident report indicated that staff were to be educated on the requirement for two-person assistance during such transfers. Interviews revealed that at the time of the incident, only one staff member was present during the transfer, despite knowing the policy required two. The staff member reported being unable to find another person to assist. Other staff, including a CNA, an LPN, and the assistant director of nursing, confirmed that the facility policy mandates two staff members for transfers using the mechanical lift. This failure to follow established policy resulted in the resident sliding out of the lift.