Lack of Documented Mechanical Lift Training Leads to Resident Fall During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff and nurse aides had documented training and competency in the use of a mechanical lift for a resident who required this device for transfers. The resident had multiple significant diagnoses, including multiple sclerosis, morbid obesity, chronic kidney disease, bilateral femur fractures, and other conditions, and was care planned to be transferred daily from bed to an electric wheelchair using a mechanical lift with the assistance of two staff. A quarterly MDS identified the resident had intact cognition and was dependent on staff for transfers. On the date of the incident, a reportable event form documented that during a transfer in the resident’s room, the mechanical lift tipped, resulting in the resident falling to the floor and complaining of left arm pain. Written statements from two nurse aides indicated they were transferring the resident from bed to wheelchair with a mechanical lift when the lift tipped over, causing the resident to fall and his/her left arm to graze the wheelchair armrest and wheel. The supervising RN’s progress note documented that upon entering the room, she observed the resident lying supine on the floor with the wheelchair nearby, complaining of left arm pain, appearing very anxious, and short of breath. The resident remained on the floor until EMS arrived and was then transferred to the hospital. An emergency room discharge summary identified that the resident had fallen from a mechanical lift, with imaging negative for fractures and a contusion on the left side of the back noted. Interviews and record review showed that the facility could not provide evidence that the two nurse aides involved had been trained or had demonstrated competency in mechanical lift use, despite facility policies requiring such training and annual competency validation. The DNS confirmed that staff are responsible for proper sling selection and positioning of the lift, including opening the base for stability, but she and the Administrator were unable to locate documentation of mechanical lift training or competency for the involved aides. RN #1, who is responsible for staff education and competency validation, stated that CNAs must receive education and demonstrate competency in mechanical lift use upon hire and annually, but confirmed that agency staff receive only a brief general orientation without mechanical lift training or competency validation, and that no documentation of mechanical lift competency for one involved aide at hire or annually could be found. Facility policies on CNA education, contracted services, and mechanical lift transfers all required safe handling, orientation, and annual competency validation, including for mechanical lifts, which were not supported by available documentation for the staff involved in this incident.
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