Improper Mechanical Lift Transfer Performed With Untrained Caregiver
Penalty
Summary
The deficiency involves the facility’s failure to follow its own mechanical lift and safe lifting policies requiring at least two trained staff members to perform mechanical lift transfers and to ensure proper sling placement and security. Facility policies state that mechanical lifting devices require two staff, that staff responsible for direct resident care will be trained in the use of mechanical lifting devices, and that sling attachments and strap stability must be double-checked before lifting. The CNA job description also requires following established safety precautions when lifting and moving residents. Despite these requirements, a CNA and a private caregiver, who was not a facility employee and had no mechanical lift training, jointly performed a mechanical lift transfer for a resident who was severely cognitively impaired, dependent for ADLs including transfers, on hospice for Alzheimer’s disease, and assessed as high risk for falls with a need for two-person assistance. On the date of the incident, the CNA and the untrained private caregiver placed the resident into a mechanical lift to transfer from bed to recliner. The private caregiver attached the top loops of the sling to the lift, and the CNA attached the bottom loops. During the transfer, as they were nearly finished and preparing to place the resident into the recliner, the resident slipped out of the bottom of the sling and fell onto the buttocks on the floor. It was later recognized that the sling had not been properly placed between the resident’s legs, which allowed the resident to slip out. The resident, who had Alzheimer’s disease and was unable to verbalize pain, was sent to the hospital, where CT scans of the spine and head/brain and a pelvic X-ray were negative for fractures or injury; the resident sustained a superficial abrasion to the left ear. The CNA’s personnel file documented prior mechanical lift training and a subsequent performance correction notice for improperly placing a mechanical lift sling.
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