Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to provide a safe mechanical lift transfer for a dependent resident with multiple diagnoses, including cerebral palsy, COPD, obesity, muscle wasting, and hypertensive heart disease. The resident, who had moderate cognitive impairment and was dependent on staff for transfers, experienced a fall during a transfer from wheelchair to bed using a mechanical lift. During the transfer, the mechanical lift tipped over and caused the resident's wheelchair to flip, resulting in the resident falling to the ground while still seated in the wheelchair. The incident was attributed to the staff not spreading the legs of the mechanical lift appropriately, which compromised the stability of the equipment during the transfer. Interviews and documentation confirmed that two staff members were present during the transfer, as required, but the mechanical lift was not used according to facility policy, which states that the base legs should be fully opened for stability. The resident did not sustain any injuries from the fall and was sent to the hospital for evaluation, where no injuries were found. The mechanical lift was inspected after the incident and found to be functioning properly, indicating that improper use by staff was the cause of the accident.