Improper Manual Transfer Performed Instead of Required Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer for a resident who required a mechanical lift, resulting in staff using an improper manual transfer with a gait belt. The facility’s Safe Lift, Transfer and Repositioning Policy and Mechanical Lift Transfer Policy required that residents who are unable to bear weight, or who are totally dependent or require extensive assistance, be transferred with a mechanical lift and full body sling. The resident’s care plan identified risks related to immobility, including potential for pressure ulcer development and high fall risk due to deconditioning and gait/balance problems, but did not include documented interventions specifying how the resident was to be transferred. The MDS showed the resident had severe cognitive impairment, was non‑ambulatory, and required maximum assistance with sit‑to‑stand, and received scheduled pain medication, with diagnoses including non‑Alzheimer’s dementia, traumatic brain injury, and heart disease. During an observed transfer, two CNAs transferred the resident using a gait belt rather than a mechanical lift. CNA D applied the gait belt by sliding it down the back of the resident’s head and along the spine. CNA C looped an arm through the resident’s right arm and grasped the gait belt behind the resident’s back, while CNA D looped an arm through the resident’s left arm and also grasped the gait belt at the back. Without first asking the resident to scoot forward or ensuring the resident’s feet were on the floor, CNA D counted to three and both CNAs lifted and pivoted the resident onto the edge of the bed. During this maneuver, CNA D stumbled and kicked the wheelchair, propelling it backward, and then set the resident on the bed with excessive force, during which the resident moaned. Interviews revealed that CNA D believed the resident was a one‑person transfer but chose to use two staff for safety, was unaware that a mechanical lift was already in the resident’s room, and did not know who updated residents’ transfer statuses. CNA D stated that if a resident can bear weight, their feet should touch the ground during transfer. The DON stated that transfer statuses are documented in the EMR and updated by the interdisciplinary team, that residents unable to bear weight should be transferred with a mechanical lift, that during a stand‑pivot transfer the resident’s feet should remain on the ground, and that staff should not loop their arms into residents’ arms or lift at armpit level. The Administrator stated that residents listed as two‑person transfers should be able to bear weight with feet on the ground, that residents totally dependent on staff for lifting should be transferred with a mechanical lift, and that transfer and mobility status changes should be updated in the care plan so staff know what type of transfer is needed.
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