Failure to Follow Two-Person Mechanical Lift Policy Resulting in Resident Fall
Penalty
Summary
The facility failed to ensure safe transfer practices by not following its policy requiring two staff members for all mechanical lift transfers. Facility policy dated 3/16 stated that use of a mechanical lift requires two nursing assistants or nurses each time it is used. Record review of a Facility Reported Incident showed that on 01/07/2026, a CNA used a mechanical lift alone to transfer Resident #30. During this transfer, the lift pad moved and the resident slipped from the lift, falling to the floor. No malfunctions were identified with the lift or lift pad. Resident #30, who had a diagnosis including paroxysmal atrial fibrillation and a BIMS score of 15 indicating intact cognition, confirmed in interview that only one CNA was present and that she was lifted high in the air when the lift strap slipped, causing her to fall straight to the ground. She reported no bruising or fractures but did sustain a broken fingernail. In a subsequent interview, CNA #1 confirmed she was alone in the room during the mechanical lift transfer when the resident began to slip and slid out of the lift pad, falling to the floor. She stated that the facility had changed the lifting method, directing staff to place lift pad straps underneath the legs instead of between the legs, and that she had attended an in-service within the last year related to this change. She also stated she was alone because other staff were unavailable at the time. The DON confirmed that an investigation found CNA #1 transferred the resident alone using a mechanical lift and reiterated that facility policy requires two staff members during mechanical lift use so that one staff member can act as a spotter if the lift begins to slip or fall. The DON also stated that CNA #1 had not completed follow-up lift training since her hire date in 2021 due to working on an as-needed basis, while confirming that staff are expected to follow the lifting policy at all times.
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