Failure to Follow Physician-Ordered Two-Person Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, anxiety disorder, and osteoarthritis, who was dependent on staff for all activities of daily living and had a physician order requiring transfer with a mechanical sit-to-stand lift and two-person assistance, was manually transferred to and from the toilet by staff. On the date in question, a certified nursing assistant (CNA) manually transferred the resident onto the toilet without assistance from another staff member and without using the required mechanical lift. The CNA then requested help from another CNA to manually transfer the resident off the toilet, again not using the mechanical lift as ordered. Interviews with staff confirmed awareness of the physician's order for two-person mechanical lift transfers, and the unit manager acknowledged that the transfer should have been performed according to the order. The facility's policy also required safe transfers per ordered status. The incident was reported by the resident's family member, and facility documentation confirmed that the staff did not follow the ordered transfer protocol for the resident.