Failure to Maintain Safe and Available Mechanical Lifts for Resident Transfers
Penalty
Summary
The facility failed to ensure that essential mechanical lifts were maintained in safe operating condition, directly affecting a resident who required a bariatric Hoyer lift for transfers. The resident, who had multiple diagnoses including morbid obesity, chronic respiratory failure, and limited mobility, was unable to transfer out of bed for a four-day period when the bariatric Hoyer lift was out of service. Staff interviews and record reviews confirmed that the resident required assistance from two staff members and a Hoyer lift with a specific sling for transfers to an electric wheelchair, as documented in the care plan. Prior to the lift becoming completely inoperable, staff had been sharing hand remotes between the bariatric Hoyer lift and a bariatric EZ stand lift for approximately two weeks because one of the remotes was not working. Maintenance staff were aware of the issue and had ordered a new remote, but there was a delay in receiving it. During this period, the facility's policy requiring mechanical lifts to be available and accessible 24 hours per day was not met, and routine checks and maintenance were not consistently documented, especially for rented equipment. Multiple staff members, including CNAs and LPNs, confirmed the lifts were not functioning and that there was confusion regarding which lifts were operational. The maintenance director acknowledged that inspections of rented lifts were not documented, and the nursing home administrator was not fully aware of the impact on the resident. Additionally, there was no staff education on timely reporting of equipment issues, contributing to the delay in resolving the deficiency.