Mechanical Lift Transfer Not Performed per Manufacturer Instructions
Penalty
Summary
Facility staff failed to perform a mechanical lift transfer according to the manufacturer's safety instructions for one resident. During an observed transfer from bed to wheelchair, two CNAs used a mechanical lift to move a resident with cerebral palsy, paraplegia, and intellectual disabilities. The resident was assessed as severely cognitively impaired and fully dependent for transfers. While lifting the resident off the bed, the CNAs kept the legs of the mechanical lift in a closed position, contrary to the manufacturer's instructions, which specify that the base should be in the widest position during lifting or lowering. Both CNAs involved in the transfer stated during interviews that they believed the lift legs should be closed when raising and lowering a resident. This practice was observed during the transfer, where the lift legs remained closed while the resident was lifted off the bed and only opened when positioning the lift around the wheelchair. The assistant director of nursing, who provides mechanical lift training, stated that the legs should be open during raising and lowering, aligning with the manufacturer's guidelines. The resident's care plan documented the need for a total mechanical lift and two-person assist for all transfers, with interventions in place due to the resident's immobility and risk for falls. Facility policy referenced the importance of following manufacturer instructions for safe mechanical lift use. Despite this, the observed transfer did not adhere to these safety protocols, as the lift was not used in accordance with the manufacturer's recommendations.