Improper Mechanical Lift Transfer Leading to Tipped Lift and Head Impact
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred properly using a mechanical (Hoyer) lift, resulting in the lift tipping while the resident was suspended in the sling. The resident had left-sided hemiplegia, atrial fibrillation, seizures, and peripheral vascular disease, and required a total mechanical lift for transfers per her care plan. A quarterly MDS indicated she had no cognitive impairment and needed moderate assistance to total dependence for ADLs. During a morning transfer from bed to wheelchair by two CNAs, the lift tipped and the resident struck her head. According to staff statements and documentation, the CNAs attempted to position the resident into the wheelchair from the side rather than from the front, despite prior instruction not to approach the wheelchair from the side when using the lift. One CNA reported that due to the resident’s size, they chose to approach from the side and opened the legs of the lift; when they pulled the resident back to position her fully in the chair, the lift tipped sideways. The resident hit the back of the wheelchair, which then reclined and contacted a dresser behind it, and the resident reported that the lift hit her head. Staff described having to stand on the lift’s base to keep it from falling onto the resident until additional help arrived. The nurse responding to the incident found the resident in the lift sling above the wheelchair with the lift tipped and called for more assistance so staff could safely seat the resident and detach the lift. Documentation showed the resident initially complained of a headache but later had no complaints, with neuro checks and vital signs completed and no redness, bruising, or edema noted to the forehead. The DON and staff interviews confirmed that two CNAs did not follow facility procedure for mechanical lift use, which required the resident’s weight to remain centered over the base legs, the boom not to be swiveled to either side, and the resident to face the attendant operating the lift at all times.
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