Improper Mechanical Lift Positioning and Unlocked Wheelchairs During Resident Transfers
Penalty
Summary
Surveyors identified deficiencies related to accident hazards and inadequate supervision during resident transfers and wheelchair use. One resident with hemiplegia, diabetes, stroke history, and intact cognition required maximal assistance for most ADLs and was care planned for transfer with an EZ Stand. During observation of a transfer by two CNAs, the resident’s knees were not positioned against the EZ Stand shin pads as the resident was raised from the wheelchair, contrary to safe positioning expectations. The facility’s mechanical lift policy required a test lift to check sling fit, attachment security, and weight distribution, but the observation focused on improper positioning of the resident’s knees during the lift. Additional deficiencies involved failure to lock wheelchairs during transfers and transporting a resident without wheelchair foot pedals. One resident with severe cognitive impairment, non‑Alzheimer’s dementia, and Down Syndrome, who required extensive assistance and mechanical lift transfers, was transferred twice by CNAs using a mechanical lift while the Broda chair or its rear wheel remained unlocked. Another resident with severe cognitive impairment, dementia, seizure disorder, and mild intellectual disabilities, who used a self‑propelled wheelchair, was transported without foot pedals and then transferred with a mechanical lift while the wheelchair remained unlocked. A further resident with hemiplegia, diabetes, COPD, and intact cognition, who was dependent for all ADLs and required a mechanical lift with two‑person assist, was transferred from bed to wheelchair with the wheelchair unlocked throughout the transfer. Staff involved in these incidents acknowledged that wheelchairs should be locked during transfers and that residents should not be transported without foot pedals, and the DON stated staff should lock wheelchair brakes during transfers and follow transfer policy.
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