Mechanical Lift Transfer Performed by Single Staff Member
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, contractures in both shoulders, and muscle wasting was transferred using a mechanical lift by a single staff member, despite the lift requiring two staff for safe operation. The resident, who was dependent on staff for all transfers and had limited functional range of motion in all limbs, was observed being lifted from a shower chair and moved approximately ten feet to her bed while suspended about three feet above the ground. During the transfer, the resident was visibly swinging as her weight shifted side to side. The Director of Nursing confirmed in an interview that two staff are required for mechanical lift transfers to prevent falls, but the facility's mechanical lift policy did not specify the number of staff required. The incident was captured on video, showing the single staff member performing the transfer and moving the resident through a 180-degree turn while she remained suspended in the air.