Improper Use of Mechanical Lift Emergency Release During Resident Transfer
Penalty
Summary
Staff failed to safely transfer a dependent resident using a mechanical lift by inappropriately using the lift’s emergency release button to lower the resident rapidly onto the bed. Facility policy for mechanical lift use required at least two CNAs, selection of an appropriate sling, ensuring the lift was stable and locked, checking attachments and sling fit, and slowly lifting and lowering the resident only as high and as fast as necessary to complete the transfer. The policy specified that residents should be gently supported and slowly lowered to the receiving surface. The resident involved had Parkinson’s disease, Alzheimer’s disease, dementia, anxiety, severe cognitive impairment, and was dependent on staff for transfers per the most recent MDS. Ring camera footage from the resident’s room showed two CNAs placing the resident in a mechanical lift sling to transfer from wheelchair to bed, with one CNA operating the controls and keeping hands on the resident. While the resident was suspended over the bed, the CNA at the controls placed a hand on the red emergency release button, verbally said “Drop him/her?” and then pressed the button, causing the resident to quickly drop onto the bed, which moved on impact, and the resident exclaimed “Oh!” The resident verbally questioned why “drop it” was said. The family member later showed the video to the DON and ADON and stated the method of lowering was unacceptable. The DON confirmed there was no reason to use the emergency release button because the lift battery was charged and there were no reports of malfunction. One CNA reported not hearing the “drop” comment, while the CNA who operated the lift admitted using the emergency release button because the lift lowered residents very slowly and stated they had never been told not to use it for transfers. The ADON and Administrator both stated the emergency release button should only be used in a real emergency when a resident needs to be removed from the lift quickly.
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