Failure to Use Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a physical therapist (PT) operated a Hoyer lift to transfer a resident from bed to wheelchair without the assistance of a second staff member. Observation confirmed that the PT performed the transfer alone, despite the resident being in the lift and requiring maximum assistance for bed transfers. Interviews with both a CNA and the PT confirmed that facility policy requires two staff members to operate the Hoyer lift for safety during transfers. The resident involved had a history of hemiplegia and Parkinson's disease, resulting in substantial to maximal assistance needs for mobility and transfers. The resident's care plan and functional assessment documented these needs, and the facility's policy, revised in July 2017, specified that at least two nursing assistants are required for safe use of a mechanical lift. The PT acknowledged operating the lift alone, which was inconsistent with both the resident's care requirements and facility policy.