Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to follow a resident's care plan and facility policy by operating a mechanical lift alone during a transfer, despite the requirement for two staff members. The resident involved had diagnoses including obesity, lack of coordination, and muscle weakness, and required maximal assistance with activities of daily living, as documented in her care plan and MDS assessment. The CNA attempted to transfer the resident back to bed after a shower using the Hoyer lift without assistance, resulting in the lift collapsing and both the resident and the lift falling to the floor. The incident led to the resident sustaining five fractured ribs, as confirmed by hospital records. The resident initially underwent an x-ray at the facility, which did not reveal concerns, but continued to experience pain and was later diagnosed with rib fractures at the emergency room. The resident reported that the CNA performed the transfer alone both to and from the shower, and that after the fall, additional staff were called to assist in returning her to bed. Interviews with facility staff, including the administrator and DON, confirmed that two staff members are always required to operate the mechanical lift, and that this policy was in place at the time of the incident. The CNA admitted to operating the lift alone, citing staffing shortages and pressure to provide care. Other CNAs on shift denied being asked for assistance. The facility's policy and staff statements consistently indicated that using the lift alone was not permitted and was considered unsafe.