Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including moderate cognitive impairment, was transferred using a mechanical lift by a single certified nursing assistant (CNA), contrary to the resident's care plan and facility policy. The care plan and recent assessments specified that transfers required the assistance of two staff members using a mechanical lift. Despite this, the CNA performed the transfer alone, removing the sling and completing the process without another staff member present. The CNA was new to the facility, on her first day of orientation, and had not yet received facility-specific training on mechanical lift transfers. The CNA stated she was aware that two people were required for mechanical lift transfers but proceeded alone because other staff were occupied and she did not request assistance. Interviews with other staff confirmed that the expectation was to use two people for such transfers, and that the CNA had been orienting with another aide who was temporarily unavailable. The resident involved did not sustain any injuries and reported not recalling how many staff usually assisted with transfers, but other residents and staff confirmed that two or more staff were typically used for mechanical lift transfers. Facility policies, as well as manufacturer and regulatory guidelines, require that mechanical lifts be operated by at least two trained staff members to ensure safety. The facility's care planning and hydraulic lift policies, as well as external guidelines from OSHA and the FDA, all support this standard. The incident was observed and confirmed through interviews and record review, demonstrating a failure to implement the comprehensive, person-centered care plan as required for the resident's identified needs.