Failure to Follow Two-Person Mechanical Lift Transfer Policy Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to morbid obesity, osteoarthritis, gait abnormalities, and generalized muscle weakness, was transferred using a mechanical lift by only one nurse aide, contrary to the facility's policy requiring two staff members for such transfers. The resident's care plan and care card both specified the need for two-person assistance during mechanical lift transfers. On the day of the incident, the assigned nurse aide performed the transfer alone because other aides were occupied, and did not request assistance from another aide who was present in the room but separated by a curtain. During the solo transfer, the sling of the mechanical lift shifted and the resident's nose was struck by the end of the sling straps, resulting in a minor nosebleed. The resident was alert and oriented, reported the incident, and denied hitting any metal part of the lift, attributing the injury to the sling straps. A subsequent assessment found no other injuries, and x-rays were normal. The resident later expressed reluctance to get out of bed, which was noted as potentially related to the incident. Interviews with staff confirmed that the nurse aide was aware of the policy requiring two staff for mechanical lift transfers and had received training on this procedure. The facility's policy explicitly stated that two trained staff are required for all mechanical lift transfers, regardless of manufacturer instructions. The nurse aide admitted to not following this policy and did not seek help from the other aide present in the room.