Failure to Obtain Therapy Assessment Before Changing Mechanical Lift Transfers for High‑Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain a comprehensive therapy assessment and to ensure treatment and care in accordance with professional standards of practice for a resident with complex medical and functional needs. The resident had severe cognitive impairment with disorganized thinking, Parkinson’s disease, non‑traumatic brain dysfunction, Alzheimer’s disease, dementia, depression, psychotic disorder, heart failure, arthritis, and unstable balance requiring human assistance. The MDS and fall risk assessment identified significant cognitive changes, high fall risk, limited ROM in an upper extremity, and dependence on staff for transfers, toileting, and lower body dressing, yet the resident was not receiving PT, OT, or restorative therapy at the time. Despite these documented deficits and high fall risk, the facility did not secure a therapy evaluation before changing the resident’s transfer method and lift type. From December through February, the resident experienced a decline in health, including acute renal failure, UTI, influenza A, dehydration, increased tremors, slurred speech, hallucinations, and increased weakness and shakiness. Nursing staff, without a therapy assessment, decided to move the resident to a bariatric stand‑up lift (SUL) based on nursing judgment when the resident became unable to stand. The DON and administrator later acknowledged that therapy should assess resident limitations and determine the safest transfer method, but therapy services were not on site from late November until early February. The RN reported that the IDT and nursing chose the bariatric SUL, which lacked a lower leg strap, and began transferring the resident with this device without prior PT/OT evaluation, even though the resident had increased tremors, difficulty aligning legs on the lift, and required assist of two for transfers. During this period, the resident experienced multiple transfer‑related incidents. On one occasion, a sling loop slid off the stand lift during transfer, and the resident was slowly lowered to the floor; a full body lift was then used to return the resident to a chair. On another occasion, while being transferred off the toilet with a Medline SUL, the resident’s legs gave out and he could no longer hold himself up; staff had to lower the lift and use a full body lift with three staff to move him to a recliner. Progress notes documented increased weakness and decline in mobility due to Parkinson’s, continued dependence on a SUL with assist of two, and the resident’s frustration with needing help for toileting and transfers. Interviews with PT, OT, the administrator, and the DON confirmed that therapy evaluation is expected to determine appropriate lift selection and safe transfer methods, and that this resident should have been assessed by therapy when his condition changed, but this did not occur prior to the nursing‑initiated changes in lift use that preceded the documented incidents.
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