Failure to Ensure Two-Person Mechanical Lift Transfer and Equipment Safety
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) attempted to transfer a resident with severe cognitive impairment, limited mobility, and total dependence for transfers, using a mechanical lift without the required assistance of a second staff member. The resident, who had diagnoses including epilepsy, contracture, and dementia with agitation, was being prepared for transfer from bed to wheelchair. The CNA positioned the resident in the sling and began lifting her before the second CNA arrived, contrary to facility policy requiring two staff for mechanical lift transfers. During the transfer, the mechanical lift sling failed, with the hooks on one side coming undone. This caused the resident to fall from the bed to the floor, resulting in lacerations to her head that required stitches and staples. The incident was witnessed after the fact by the second CNA, who arrived to find the resident on the floor. The resident was assessed by nursing staff, and emergency medical services were called for further evaluation and treatment at the hospital. The resident returned to the facility the same day and was monitored post-fall. Interviews and record reviews confirmed that the CNA was aware of the two-person requirement for mechanical lift transfers but proceeded alone. The facility's policies clearly stated that at least two nursing assistants are needed for safe mechanical lift use, and that slings and equipment must be inspected for defects prior to use. The sling used in the incident was found to be defective, and the CNA did not wait for assistance before initiating the transfer, directly leading to the resident's fall and injury.