Failure to Follow Two-Person Mechanical Lift Transfer Policy
Penalty
Summary
The facility failed to follow its policy requiring two staff members to assist with transfers using a mechanical sit-to-stand lift. On the observed date, a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) initially transferred a resident from a wheelchair to a toilet using the sit-to-stand lift together. However, when the resident needed to be transferred back to the wheelchair, the CNA performed the transfer alone, without waiting for the RN as required by facility policy and procedure. The CNA stated she did not wait for the RN because the resident was becoming agitated. The RN confirmed she was not present and did not hear the CNA calling for assistance. The resident involved had a history of dementia with behavioral disturbances, late-onset Alzheimer's disease, and was assessed as having severely impaired cognitive status. The resident's care plan identified risks related to impaired mobility, cognitive impairment, poor safety awareness, and a need for two-person assistance with mechanical lift transfers. Facility policies, staff interviews, and documentation all confirmed that two staff are required for such transfers to ensure resident safety. The failure to follow this protocol resulted in a deficiency related to accident prevention and adequate supervision.