F0656

D

Failure to Follow Care Plan Requiring Two-Person Mechanical Lift Transfer

Franklinton, Louisiana Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure staff accurately implemented a comprehensive care plan requiring a 2-person total body mechanical lift transfer. The resident involved was admitted with multiple diagnoses including lack of coordination, dementia, Parkinson’s disease, repeated falls, transient cerebral ischemic attack, abnormalities of gait and mobility, forms of tremor, and muscle weakness. An MDS with an ARD of 12/22/2026 showed a BIMS score of 15, indicating the resident was cognitively intact. A Transfer/Mobility Criteria assessment documented that the resident was totally dependent on staff for ADL support and required use of a total mechanical lift with full body sling. The current plan of care identified the resident as at risk for falls and specified an ADL intervention of a total body mechanical lift with 2 staff members for transfers.

Despite these documented requirements, the resident reported that on a night shift, a CNA transferred him from his wheelchair to his bed using the mechanical lift while she was the only staff member in the room. He stated that during the transfer he began having jerking movements and felt like he was going to fall. The CNA confirmed that she worked that night and that when the resident requested transfer, she initially requested assistance from another CNA. While waiting, the resident became anxious, rocked back and forth, and attempted to slide himself out of the wheelchair. The CNA stated she believed the resident was at risk of falling to the floor and proceeded to transfer him with the total body mechanical lift without a second staff person, acknowledging that she should have had another staff member present. The DON confirmed that for all residents, total body mechanical lift transfers are to be completed with 2 staff members under any circumstance.