Failure to Use Two Trained Staff During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure appropriate supervision and adherence to policy during a mechanical lift transfer, resulting in a resident sliding from the lift. Resident #31 was admitted on 08/06/25 with diagnoses including cerebral infarction, COPD, and respiratory failure, and the MDS dated 11/13/25 documented that the resident was dependent on staff for transfers between surfaces. On 12/03/25 at 6:00 P.M., nursing progress notes recorded that the resident slid out of a Hoyer mechanical lift during a transfer and was subsequently assessed by staff and sent to the emergency room for evaluation. A hospital note confirmed the resident was evaluated in the emergency department for a fall from a mechanical lift and then returned to the facility. During interviews, the DON confirmed that on 12/03/25 the resident slid from the Hoyer lift while being transferred and that the transfer was performed by CNA #111 and the resident’s family member. The DON stated that facility policy requires two trained staff members for all mechanical lift transfers and that her expectation is that at least two trained staff always operate mechanical lifts. CNA #111 reported that she was transferring the resident from a chair to a bed using a Hoyer lift when the resident’s family member offered to assist; although the CNA said she would find another staff member, the family member insisted and the transfer was completed by the CNA and the family member. CNA #111 stated she attempted to reposition the Hoyer pad under the resident’s knees before initiating the lift, and when she began lifting, the resident started screaming and jiggling; she then lowered the lift and the resident slid to the floor. CNA #111 confirmed the resident had required a Hoyer lift since admission and was always a two-person assist for transfers with trained staff, and review of the facility’s Mechanical Lift policy dated 07/15/25 reiterated that staff must use the required number of trained staff and follow manufacturer instructions during transfers.
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