Mechanical Lift Transfer Conducted Without Required Second Staff Member
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member. The resident involved had diagnoses including normal pressure hydrocephalus, hemiplegia, and dementia, and was cognitively impaired, requiring total staff assistance for activities of daily living. The resident's care plan and physician orders specified the use of a mechanical lift with two staff members for all transfers. Observation revealed that the CNA entered and exited the resident's room with the mechanical lift alone, and later confirmed in an interview that she performed the transfer without a second staff member present, despite being trained and aware of the policy. Review of the facility's policy also confirmed that two staff members are required for mechanical lift transfers. This incident was discovered during a complaint investigation.