Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, below-knee amputation, hypertension, anemia, chronic kidney disease, unsteadiness, and a history of falls was not provided adequate supervision and assistance during a mechanical lift transfer. The resident was care planned to require a mechanical (Hoyer) lift with the assistance of two staff members for all transfers due to their high level of dependency and cognitive impairment. Despite this, a CNA attempted to transfer the resident alone using the mechanical lift. During the transfer, the CNA failed to properly connect one of the lift straps, resulting in the resident beginning to fall backward. The CNA intervened by holding and guiding the resident to the floor. Upon assessment, the resident was found lying on their back, denied pain, and exhibited no injuries, though it was noted that the resident's head made contact with the floor. Vital signs and neurological checks were within normal limits, and the resident's power of attorney and physician were notified. The CNA later confirmed that this was the first time they had attempted a mechanical lift transfer without a second staff member present. The facility's policy clearly required two staff for all mechanical lift transfers, and this policy was not followed at the time of the incident. There were no other reported complaints or concerns related to unsafe transfers prior to this event.