Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
Facility staff failed to provide adequate supervision and follow established safety procedures during the use of a mechanical sit to stand lift for a resident with a history of COPD, stroke, and one-sided weakness. The resident was dependent on staff for toileting and hygiene and was identified as being at risk for falls, with care plans specifying the use of a sit to stand lift with two staff members for all transfers. On the date of the incident, staff were providing incontinent care and used the lift, but one staff member left the room, leaving the resident with only one staff member present. This deviation from protocol resulted in the resident sliding out of the lift and falling. The DON confirmed that staff did not adhere to facility safety procedures by both using the lift during cleaning and by leaving the resident unattended by the required number of staff.