Failure to Train Staff on Proper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that staff were properly trained in the use of mechanical lift transfers, resulting in an improper transfer of a resident who was dependent on staff for mobility. The resident, who had chronic osteomyelitis, anxiety, and abnormal gait and mobility, was care planned to require a mechanical lift with two staff for all transfers. On the day of the incident, two nurse aides, one of whom was in training, attempted to transfer the resident using a mechanical lift. The aides used a sling pad that was too small, and the pad was improperly placed, causing the resident's right leg to be unsupported and in pain. Despite the resident expressing discomfort and refusing the transfer, the aides continued, and during the process, the resident's leg was injured and a latch on the lift pad slipped, causing the resident to nearly fall. Interviews revealed that neither aide had previously transferred this resident, and the aide in training took over the transfer process, which was not appropriate. The DON confirmed that there was no formal training protocol for mechanical lift transfers in place at the facility, and that staff were expected to train each other without documentation or structured guidance. Facility policy required that only trained and qualified caregivers perform such transfers and that the proper size sling be used, but these requirements were not met in this instance.