Failure to Use Two Staff for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with hemiplegia, hemiparesis, weakness, obesity, and vascular dementia was transferred using a mechanical lift by only one nurse aide, despite physician orders and facility education requiring two staff members for all mechanical lift transfers. The staff education materials and clinical records confirmed that two staff are necessary for safe transfers, and this requirement was acknowledged by both the nurse aide and the LPN during interviews. Observation revealed that the nurse aide performed the transfer alone, lowering the resident into bed without assistance. The nurse aide admitted to not following the two-person protocol, and the LPN and Nursing Home Administrator both confirmed that two staff are required for mechanical lift operations. No facility policy was provided for review.