Unsafe Mechanical Stand Lift Transfer and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical stand lift and to provide adequate supervision to prevent an accident. The resident had multiple diagnoses, including hypertensive heart disease, chronic kidney disease stage 4, atrial fibrillation, type 2 diabetes, repeated falls, reduced mobility, depression, generalized osteoarthritis, and anxiety, and was care planned as high risk for falls with use of a stand lift for transfers. The day before the incident, the resident had a documented fall due to weakness. On the day of the incident, an agency CNA (V8) reported that she knew the resident was a two-person assist or mechanical stand lift transfer and attempted to find another staff member to help, but when no one was available, she proceeded to use the stand lift alone. During the transfer, V8 placed the sling under the resident’s armpits and secured the belt around the resident’s chest, rather than around the waist as described by the restorative CNA (V5) as the correct method. V8 stated that as the transfer was in progress, the resident’s legs gave out, the resident began to slip from the sling strap, and then fell, striking her lower back on the floor. V8 acknowledged this was her first time working at the facility and that she did not know two staff were required for mechanical stand lift transfers, and she also reported that she and another CNA lifted the resident off the floor and into a wheelchair after the fall. The DON (V2) confirmed that the facility’s policy, revised in 2019, requires two staff for all mechanical lift transfers, that staff should not move a resident after a fall until a nurse assesses the resident, and that the stand lift arms were found in an upright position, which can cause the sling to ride up the back. The incident report documented that the resident slipped out of the sit-to-stand machine and that V8 moved the resident off the floor after the fall.
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