Failure to Ensure Safe Resident Transfers and Use of Transfer Equipment
Penalty
Summary
Staff failed to provide safe transfers for two residents, as observed during surveyor visits. In one instance, a CNA assisted a resident with toileting by pulling the resident up to a standing position using her forearm under the resident's armpit, rather than using a gait belt as required by facility policy. The resident's care plan indicated a need for one-person assistance with toileting and personal hygiene, and the MDS assessment showed the resident was dependent on staff for toileting and required partial to moderate assistance with transfers. Facility policy specified that staff should use appropriate techniques and devices, such as gait belts, for lifting and moving residents, and staff were expected to be trained in these procedures. In another case, a CNA used a mechanical stand lift to transfer a resident with severe cognitive impairment and multiple diagnoses, including seizure disorder and COPD. The CNA failed to lock the lift brakes before raising the resident from the toilet and again before lowering the resident into a wheelchair, contrary to the operator's manual instructions. The resident's care plan required the use of a mechanical stand lift with one-person assistance for transfers. The administrator confirmed that staff should follow the operator's manual when using the mechanical stand lift.