Improper Mechanical Lift Use and Inadequate Assistance During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and to provide adequate supervision and use of appropriate transfer equipment during a mechanical lift transfer. A female resident with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and with moderate cognitive impairment (BIMS score of 8), was care planned as dependent for transfers and required use of a full body lift with two-person assistance. The resident’s care plan specified assistance with transferring using a full body lift with two staff, but the physician’s orders did not contain specific transfer or mechanical lift instructions. On the date of the incident, CNA A attempted to transfer the resident without following the care plan. CNA A reported that when a full body sling could not be found in the resident’s room, they used a standing lift instead. CNA A also stated that no one was helping with the standing lift because other staff were busy and that, although two people were usually used when not busy, on this occasion the transfer was performed alone. This was CNA A’s first time caring for the resident, and CNA A stated they did not know the resident was not supposed to use the standing lift and that they sometimes used a standing lift if full body lifts were busy. During the transfer from bed to chair using the standing lift, CNA A stated the resident chose to sit on the floor and was slowly lowered to the floor. The DON reported that the aide had to lower the resident to the floor during the transfer and then notified the charge nurse. The resident was assessed by nursing staff at the time and initially denied pain, with no injuries noted on head-to-toe assessment. Later, the resident complained of right shoulder and bilateral knee pain and was evaluated at the hospital, where imaging studies showed no acute intracranial abnormality and no fractures, and subsequent notes documented intact skin and no new orders. The unit manager stated that there were always supposed to be two people when transferring residents with either a standing or full body lift, and the facility’s transfer policy required use of the correct lift and two-person assistance for all lift transfers.
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