Failure to Provide Sufficient Staff During Mechanical Lift Transfer Resulting in Resident Harm
Penalty
Summary
Facility staff failed to follow established protocols requiring two nursing assistants to perform a mechanical lift transfer for a resident with morbid obesity, dementia, and muscle weakness. The resident was assessed as dependent for bed mobility and transfers, with care plans and physician orders specifying the need for extensive assistance of two staff members during transfers using a stand-up lift. Despite these requirements, a nurse aide conducted a transfer alone, contrary to facility policy and the resident's care plan. During the transfer, the resident fell from the mechanical lift. The nurse aide initially reported that the sling broke during the transfer, but subsequent inspection by staff and interviews revealed no evidence of damage or defect to the sling. The incident resulted in the resident sustaining multiple skin tears to the left forearm, hand, and wrist, as well as bruising to the head and face. The resident experienced severe pain, with pain levels reported as high as 10 out of 10, and required transfer to the hospital for further evaluation and treatment. Documentation and interviews confirmed that only one staff member was present during the transfer, in violation of facility policy, the resident's care plan, and physician orders. There was no evidence that the equipment was defective, and the failure to have sufficient staff directly led to the resident's fall and subsequent injuries.