Failure to Ensure Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe dementia, hemiplegia, hemiparesis, muscle weakness, and a history of subarachnoid hemorrhage, who was dependent on staff for all activities of daily living and required two-person assistance for mechanical lift transfers, was transferred by only one nurse aide using a mechanical lift. The resident was noted to be fidgety, anxious, restless, and flailing arms at the time of the transfer. Despite these behaviors, the nurse aide proceeded with the transfer alone, contrary to the resident's care plan and facility policy, which required two staff members for such transfers. During the transfer, one of the loops on the lift sling became detached from the hook, causing the resident to tip forward in the sling and strike their head on the mast of the lift. The nurse aide admitted to being in a rush and failing to ensure all loops were securely attached before lifting the resident. After the incident, the nurse aide lowered the resident back into the wheelchair, secured the loop, and completed the transfer to bed without notifying a nurse or reporting the incident at that time. The resident was later found by an LPN to have a raised, discolored area above the right eye and minor bleeding near the right ear, which had not been present earlier. Due to the resident's cognitive impairment, they were unable to communicate what had happened. The incident was initially treated as an injury of unknown origin until the nurse aide later reported the accident. Interviews with other staff confirmed that no one assisted the nurse aide during the transfer, and the required safety checks and reporting procedures were not followed.