Failure to Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident with hemiplegia and hemiparesis using a mechanical lift, as required by the resident's care plan and facility policy. The resident, who was cognitively intact but dependent for transfers, was to be transferred with a Maxi Lift (Hoyer lift) using an extra-large blue sling and the assistance of two staff members. During a transfer, staff were unable to secure all four sling straps due to the resident's complaints of pain and suspected the sling might be the wrong size. Despite this, the transfer was attempted with only three straps secured, with one staff member manually supporting the unsupported limb. While the resident was suspended over the bed, the lift's wheel became obstructed by a cord on the floor. Staff attempted to push the lift over the cord, resulting in the resident sliding out of the sling and falling to the floor. The incident led to the resident sustaining fractures to the C6 and C7 spinous processes, as confirmed by a hospitalization summary. Facility policy and the Director of Nursing Services specified that all four straps must be secured and the area cleared prior to transfer, but these procedures were not followed during the incident.