Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a mechanical lift in accordance with safety protocols during a resident transfer. Facility documentation, including the Invacare User Manual, specified that the legs of the lift must be fully opened for maximum stability and safety. Clinical records showed that a resident with muscle weakness and difficulty walking, who required two-person assistance for transfers using a Hoyer lift, was involved in an incident where the lift tipped over during a transfer from chair to bed. Nursing notes and facility investigation confirmed that the resident was lowered to the floor after the lift tilted to the side over one of the nurse aides present. Interviews and observations with the nurse aide involved revealed that the Hoyer lift legs were not widened at the time of the transfer, which directly led to the device tipping. The aide demonstrated the transfer process and confirmed the improper use of the lift. Further interviews with facility leadership, including the Administrator and DON, verified that the lift legs are required to be widened during transfers, confirming that the established safety procedures were not followed in this instance.