Failure to Follow Manufacturer Guidelines During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe practices were followed according to the manufacturer's guidelines during the transfer of a resident using a mechanical lift. Specifically, two CNAs were observed assisting a resident with a mechanical lift transfer and locked the lift's back wheels while lowering the resident into a wheelchair. Multiple staff members, including CNAs and nursing leadership, provided conflicting information during interviews regarding whether the lift wheels should be locked or unlocked during the lowering process. However, review of manufacturer guidelines and staff competency evaluations confirmed that the wheels should remain unlocked when lowering a resident to prevent the lift from tipping. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, rheumatoid arthritis, polyneuropathy, and muscle spasms, and was totally dependent on two staff members and a mechanical lift for all transfers. The care plan and staff training materials indicated the correct procedure, but staff practice did not align with these guidelines during the observed transfer. The facility did not have a specific policy for mechanical lift transfers and relied on manufacturer instructions, which were not consistently followed by staff.