Failure to Provide Required Assistance During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide independently transferred a dependent resident using a mechanical lift without the required assistance of a second staff member. The resident, who had a history of traumatic brain injury, abnormal posture, and multiple contractures, was totally dependent on staff for transfers and had severely impaired cognitive skills. During the transfer from bed to a reclining wheelchair, the mechanical lift tilted, causing the sling bar to strike the resident above the left eyebrow, resulting in a laceration. The nurse aide admitted to performing the transfer alone, despite being aware of the facility's policy requiring two-person assistance for mechanical lift transfers. She stated that she had attempted to find another staff member to assist but proceeded alone when no one was available. The incident was immediately reported to nursing staff, who assessed the resident and arranged for transfer to the emergency department. The resident received sutures for the laceration and returned to the facility the same day. Interviews with staff confirmed that the nurse aide had received prior training on the mechanical lift policy and was aware of the requirement for two-person assistance. The Director of Nursing and Administrator both verified that the nurse aide acknowledged her actions and the deviation from policy. Observations and record reviews indicated that the resident had a healing scar from the injury, and there were no signs of infection or ongoing pain at the time of follow-up.