Failure to Ensure Competency of Agency Staff in Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that new staff, specifically agency nurse aides, were competent to properly and safely administer mechanical lift transfers for a resident with significant mobility and cognitive needs. The resident, who was dependent for transfers and required the use of a mechanical lift with two staff and a specific sling, was transferred by two nurse aides—one of whom was an agency hire on their first day at the facility and had not been skill checked or educated on the facility's mechanical lift procedures. During the transfer, only three out of four sling straps were secured, and when the lift encountered an obstruction, the resident slid out of the sling and fell, resulting in serious injury including fractures to the C6 and C7 spinous processes. Interviews and documentation confirmed that the agency nurse aide had not received facility-specific training or competency assessment for mechanical transfers prior to participating in the transfer. The facility's policy required staff to be educated on safe handling and transfer practices upon hire, but this was not enforced for agency staff, as the expectation was that they were already trained. The incident was witnessed by both aides involved, and the lack of proper skill verification and adherence to transfer protocols directly contributed to the resident's fall and subsequent injuries.