Failure to Provide Adequate Supervision During Hydraulic Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used a hydraulic lift to transfer a resident without the required assistance of a second staff member. The resident involved was a male with significant medical conditions, including cerebrovascular disease, right-sided hemiplegia, peripheral vascular disease, dementia, major depressive disorder, and bipolar disorder. He was bedbound, severely cognitively impaired, and dependent on staff for all activities of daily living, including transfers, which required the use of a hydraulic lift and two staff members for safety. On the day of the incident, the CNA proceeded to obtain the resident's weight alone using the lift because her assigned partner was late and other staff were unavailable, despite being trained and aware of the policy requiring two staff for such transfers. Further review revealed that the resident's comprehensive care plan did not include specific interventions or instructions regarding the use of a hydraulic lift and transfer assistance, even though this was necessary for his care. Interviews with facility leadership, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that two staff are required for all hydraulic lift transfers and that the resident's care plan should have reflected this need. The facility's policy and CNA training materials also specified the two-person requirement for mechanical lift use.