Failure to Ensure Safe Mechanical Lift Transfer Procedures
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards related to the improper use of a mechanical lift, as required by facility policy. The policy specified that two staff members must assist with mechanical lift transfers to ensure resident safety, dignity, and comfort. Despite this, a certified nursing assistant (CNA) attempted to transfer a resident with significant mobility impairments using a mechanical lift without the required second staff member. The resident's care plan and Kardex clearly indicated the need for two-person assistance during transfers. The incident involved a resident with a history of stroke, hemiplegia, and impaired mobility, who was dependent on staff for transfers. During the transfer from a chair to a bed, the CNA was unable to find another staff member to assist and accepted help from the resident's family member instead. The mechanical lift did not clear the bed properly, and as the CNA attempted to maneuver the resident onto the bed, the lift made contact with the base of the geriatric chair. This caused the resident's weight to shift, resulting in the lift tilting and the resident being lowered to the floor by the CNA and family member. Following the incident, the resident complained of pain and was sent to the emergency department, where imaging showed no fractures or acute injuries. Interviews with staff and the family member confirmed that the transfer was performed by only one staff member, contrary to facility policy and training. The CNA admitted to acting impatiently and not following the required procedure for mechanical lift transfers.