Failure to Provide Two-Person Assistance During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a male resident with cerebral palsy, hemiplegia, and borderline intellectual functioning from his bed to his motorized wheelchair using a mechanical lift without the required assistance of a second staff member. The resident's care plan and facility policy both specified that mechanical lift transfers must be performed by two staff members. Despite having received recent training and competency checks on this procedure, the CNA conducted the transfer alone. Following the transfer, the resident went outside in his motorized scooter. While moving along the sidewalk, he fell to the left side onto the pavement, sustaining a left shoulder fracture and skin tears to his right hand and face. The resident reported that a strap from his mechanical lift vest became tangled in the wheel of his scooter, causing the fall. The incident was witnessed and documented by facility staff, and emergency medical services were called to assist the resident, who was subsequently transported to the hospital and diagnosed with a left shoulder fracture. Interviews with the resident, responsible party, and facility leadership confirmed that the transfer was performed by only one staff member, contrary to policy and training. The resident expressed feeling unsafe during the transfer and was aware that two-person assistance was required. Facility records showed that the CNA involved had received recent in-service training and had signed off on the policy requiring two staff for mechanical lift transfers.