Failure to Use Required Two-Person Assistance for Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure safe transfers and adequate supervision when a nursing assistant (NA-A) transferred a resident (R5) alone using an EZ Stand mechanical lift, despite the resident’s care plan and facility practice requiring two staff for all mechanical lift transfers. R5’s annual MDS indicated intact cognition, dependence on staff for all transfers, and diagnoses including heart failure and morbid obesity. R5’s care plan dated 6/3/24 documented the need for assistance of two staff with the EZ Stand and identified a risk for falls related to impaired mobility, and a subsequent care plan dated 9/3/24, as well as orders dated 2/10/26, specified “care in pairs.” Provider notes documented that R5 weighed 543 pounds. During an observation, surveyors saw NA-A exit R5’s room alone with the EZ Stand after R5 thanked her for helping her out of bed, with no other staff present in or near the room. In interviews, R5 confirmed that only NA-A assisted with the EZ Stand transfer and reported that staff sometimes used one person instead of two when another staff member could not be found. Staff member E-J stated that R5 required two staff for EZ Stand transfers and that all residents using mechanical lifts required two staff. NA-A acknowledged transferring R5 without a second staff member, stated she was aware R5 was supposed to have care in pairs due to past allegations against staff, and admitted she should have waited for help and that she knew she could get in trouble and that injury could occur without another staff present. Another employee, E-D, stated R5 always transferred with two staff for safety and that if she observed a one-person EZ Stand transfer, she would educate the staff on safe transfer procedures. The DON confirmed that all mechanical lifts in the facility required two staff for safe transfers and that staff could seek assistance from various nursing personnel or wait for help. The facility’s Fall Prevention and Management policy indicated staff would identify and implement relevant interventions to minimize serious consequences of falling.
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