Failure to Follow Mechanical Lift Transfer Protocols Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a nurse aide (NA) transferred a resident with hemiplegia and hemiparesis using a mechanical lift without the required assistance of a second staff member, contrary to facility policy. The resident, who was alert, oriented, and dependent for transfers, was being moved from a wheelchair to bed when the NA attached the lift sling incorrectly. The right upper side of the sling did not lock completely, and as the resident was lifted, the hook separated, causing the resident to slide onto the floor. The resident complained of shoulder pain following the fall and was sent to the hospital, where imaging revealed a left anterior shoulder dislocation consistent with a chronic subluxation. Documentation and staff interviews confirmed that the NA was aware two staff were required for mechanical lift transfers but proceeded alone due to lack of available staff. Facility policy and the resident's care plan both specified the need for two staff during such transfers, which was not followed in this incident.