Improper Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and toileting due to lower extremity impairment and other medical conditions, was improperly transferred using a mechanical lift. The resident had a BIMS score indicating cognitive intactness and required two staff members for safe transfer according to facility policy. On the day of the incident, a CNA responded to the resident's call light and, despite knowing the policy, attempted to transfer the resident alone using a sit-to-stand lift. During the transfer, the resident slipped out of the straps and fell, resulting in a head injury and a 1.2 cm laceration that required three staples. The facility's investigation and interviews confirmed that the CNA did not wait for a second staff member before using the mechanical lift, which was against established policy. The resident's emergency room records corroborated the account of the fall and injury. The root cause analysis identified improper use of the mechanical lifting device as the cause of the incident. Facility policy clearly stated that at least two nursing assistants are required for such transfers, but this protocol was not followed in this instance.