Failure to Use Two-Person Mechanical Lift Transfer as Required
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance devices during a mechanical lift transfer for one resident. The resident was an older female with COPD, muscle weakness, unspecified pain, Type 2 DM with complications, and a history of cerebral infarction. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented that she was dependent for chair/bed-to-chair transfers, requiring the assistance of two or more helpers. Her care plan, initiated earlier, addressed risk for pressure injury related to decreased mobility, incontinence, poor nutrition, history of skin breakdown, fragile skin, Braden risk score, and sensory perception, but did not address ADLs or means of transfer. On the day of the incident, the CNA Kardex for this resident indicated that her chair/bed-to-chair transfer required two persons. Despite this, a CNA was observed transferring the resident alone from bed to chair using a mechanical lift, with no other staff present. The DON, upon arriving at the scene, stated that two people were needed for mechanical transfers. In an interview, the CNA acknowledged she had been trained that two staff were required for mechanical lift transfers for the safety of residents and staff, but reported she proceeded alone because the other CNA on the hall was busy and the resident, who was her family member, was urging her to get her up quickly. Interviews and record review showed that the facility had established policies and training requiring two staff for mechanical lift transfers. The DON stated that staff were informed of residents’ mechanical lift needs during shift report and that CNAs used the Kardex to identify transfer requirements. The MDS nurse stated she was responsible for care plans and that the resident’s need for mechanical lift transfer should have been care planned but was overlooked, even though the MDS documented the resident as dependent for transfers. Facility policies on mechanical lifts, safe resident handling/transfers, and accident and supervision all required two staff for mechanical lift transfers and emphasized safe handling based on the resident’s individual plan of care and assessed needs, but in this case the resident’s transfer method was not included in the care plan and the transfer was performed by a single CNA contrary to policy and documented requirements.
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