Failure to Provide Required Two-Person Assist During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers due to hemiplegia, hemiparesis, and aphasia following a stroke, was transferred using a mechanical lift by a single CNA instead of the required two-person assist. The resident's Minimum Data Set assessment indicated a need for two or more staff members for transfers, and facility policy mandated at least two nursing assistants for safe use of a mechanical lift. Despite these requirements, the CNA attempted the transfer alone, resulting in the resident slipping from the sling and falling to the floor. As a result of this incident, the resident sustained a large intramuscular hematoma to the right pectoralis and minimally displaced fractures of the right proximal tibia and fibula. Interviews with facility staff, including the MDS Coordinator, Licensed Nurse, and DON, confirmed that the resident required two-person assistance and that the CNA did not follow established policy and procedures. The DON acknowledged that the resident's injuries were acquired due to the fall caused by the failure to implement the required two-person assist during the transfer.