Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, dementia, and muscle weakness, who was dependent on staff for all transfers, was transferred using a mechanical stand-up lift by a single nurse aide, contrary to facility policy, care plan, and physician orders that required the assistance of two staff members. The nurse aide performed the transfer alone, and during the process, the resident fell from the lift. The incident resulted in the resident sustaining multiple skin tears to the left forearm and hand, bruising to the head and face, and experiencing severe pain, which ultimately required hospitalization for evaluation and treatment. Facility documentation and staff interviews confirmed that the mechanical lift and sling were not defective or broken, and the failure was attributed to the lack of a second staff member during the transfer. The resident's care plan and physician orders clearly specified the need for two-person assistance with all mechanical lift transfers, and the facility's policy reinforced this requirement. Despite these directives, the nurse aide proceeded with the transfer alone, leading to the resident's fall and subsequent injuries. The investigation further revealed that the environment was not maintained free from accident hazards, as required by regulation, due to the improper use of the mechanical lift and lack of adequate supervision. The resident reported significant pain following the incident, and clinical observations documented active bleeding and multiple wounds. The facility's failure to ensure adherence to safe transfer techniques and supervision directly resulted in actual harm to the resident.