Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis and left-sided weakness, who was assessed as requiring two staff members and a mechanical lift for safe transfers, was transferred by only one agency CNA using the mechanical lift. Despite the resident reminding the CNA that two staff were needed, the CNA proceeded alone. During the transfer to the shower chair, the chair moved and tipped over, causing both the resident and the chair to fall to the floor. The resident reported that the mechanical lift sling broke the fall, preventing injury. Facility records and staff interviews confirmed that the resident consistently reported being transferred by one staff member, contrary to the care plan which required two staff for safety. The incident was reported to the nursing staff the following morning, and the assistant administrator confirmed that the agency CNA involved was placed on do not return status. The facility's failure to follow the resident's care plan and provide adequate supervision during the transfer resulted in an accident hazard and an actual fall.