Inadequate Two-Person Assistance During Mechanical Lift Transfer Causes Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer of a resident using a mechanical lift, resulting in an 8 cm laceration that required 11 sutures. A CNA (V4) reported that on 1/15/26 she transferred the resident (R1) alone from wheelchair to bed with a mechanical lift, despite having been taught that two staff members are required for such transfers. V4 stated she chose to perform the transfer by herself because she believed the resident was light and easy to move, and described that the resident had extreme anxiety with care, “freaks out” during mechanical lift transfers, and was shaking during the transfer. V4 stated she thought the resident may have bumped his leg on the bed while he was “freaking out and shaking.” A nursing progress note from that date documented that during the transfer the resident hit his lower leg on the bed, resulting in an open laceration measuring about 7 cm, and the ER physician report documented an 8 cm left leg laceration closed with 11 sutures. Interviews with the DON, ADON, restorative/QA nurse, LPNs, and CNAs confirmed that facility practice and expectation are that two staff are required for mechanical lift transfers, with one staff operating the lift remote and the other supporting and positioning the resident to prevent contact with surrounding objects. The mechanical lift manufacturer’s representative also stated that two caregivers are required to safely operate the lift, with one operating the lift and the second guiding the patient. The resident’s face sheet and MDS showed multiple diagnoses including muscle wasting and atrophy, gait and mobility abnormalities, lack of coordination, chronic heart failure, peripheral vascular disease, osteoarthritis, end stage renal disease, a history of falling, and that he was completely dependent on the assistance of two or more helpers for transfers. A restorative assessment documented that he was fully dependent on staff for chair/bed transfers and used a mechanical lift. The facility’s Limited Lifting Resident Handling Policy stated that mechanical lifting devices shall be used for any resident needing a two-person assist, but the resident was transferred by only one staff member at the time of the incident.
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