Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
Surveyors identified a deficiency related to the unsafe use of a mechanical lift during a transfer. During observation, two CNAs transferred Resident #13 from bed to wheelchair using a mechanical lift with the lift’s legs kept closed while the resident was raised, backed away from the bed, turned, and moved toward the wheelchair. The legs of the lift were only opened once the device was positioned directly in front of the wheelchair to fit around it, rather than at the earliest opportunity after the lift was no longer under the bed. The resident’s care plan indicated he usually required two-person assistance with a mechanical lift for bed-to-chair transfers, and progress notes showed the facility used a mechanical lift to obtain his weight at admission. Resident #13 had a BIMS score of 5/15, indicating severely impaired cognition, and diagnoses including a left lower leg fracture, stroke, and constipation. A physician’s order directed that he remain non–weight bearing on his left lower leg for 8–12 weeks. Staff interviews confirmed that facility practice and training were that the mechanical lift’s legs should be opened when moving a resident and only closed briefly when necessary to accommodate barriers, with the DON stating staff should have opened the legs at the first available moment. The facility’s mechanical lift policy and the manufacturer’s user manual both specified that the lift legs must be in the maximum open position for optimum stability and safety, and that any closing of the legs under a bed should be temporary and reversed as soon as the lift is no longer under the bed.
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