Failure to Follow Safe Mechanical Lift Transfer Procedures Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow safe transfer techniques while using a mechanical lift to transfer a resident with significant physical and cognitive impairments. The resident, who had hemiplegia, hemiparesis, dementia, and was dependent in all self-care and mobility, required a mechanical lift with two staff for all transfers. During a transfer from bed to chair, two State Registered Nurse Aides (SRNAs) operated the lift, but did not extend the legs of the device as required for stability. One SRNA pulled on the lift pad to position the resident, causing the lift to become unbalanced and tilt. As a result of the improper use of the mechanical lift, the device's bar struck the resident on the back of the head, causing a laceration and hematoma. The resident required emergency medical attention, including staple closure of the wound and a CT scan to assess for further injury. Documentation and witness statements confirmed that the lift's legs were not extended due to the way the device was positioned under the chair, and that the staff involved did not follow established procedures for safe resident handling and transfer. The facility's investigation found that the incident was not due to equipment malfunction, as maintenance staff confirmed the lift was functioning properly. The incident was attributed to staff not adhering to the facility's policies and procedures for mechanical lift use, specifically the failure to extend the lift's legs and improper handling during the transfer. The staff involved were interviewed, and one was terminated for failure to use proper lifting techniques and non-compliance with training.