Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, seizure disorder, and total dependence on staff for all activities of daily living, including transfers, was injured during a transfer using a mechanical lift. The resident's care plan specified the need for two staff members to assist with all mechanical lift transfers. Despite this, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone using a Hoyer lift, contrary to facility policy and the resident's care plan. During the transfer, the CNA raised the resident in the sling and attempted to move her toward a wheelchair. The resident began to lean forward and subsequently fell out of the sling, landing face-first on the floor. The CNA immediately called for nursing assistance. Upon arrival, nursing staff found the resident on the floor with significant head trauma, including a forehead laceration, nasal fracture, and multiple skin tears. Emergency services were called, and the resident was transported to the hospital for further evaluation and treatment. Interviews and documentation confirmed that the CNA did not request assistance from another staff member prior to the transfer, despite knowing that two staff were required. The CNA stated that other staff were occupied and felt she had no other choice but to proceed alone. Facility policy explicitly required two staff for all mechanical lift transfers, and this policy was not followed in this instance, directly leading to the resident's fall and injuries.