Failure to Provide Required Two-Person Assistance and Safe Technique During Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistive devices during transfers for a resident who required a Chorus stand-up lift with two-person assistance. The resident had multiple diagnoses, including COPD, a Stage IV pressure ulcer, neuromuscular bladder, tremors, repeated falls, mild vascular dementia, and cognitive communication deficit, and was identified as high risk for falls. Physician orders, the Kardex, therapy documentation, and the MDS all indicated that the resident was dependent for transfers and required either a Chorus or mechanical lift with two staff assisting. Despite these orders and documented needs, the resident experienced three separate witnessed falls or lowering-to-the-floor events during transfers when only one agency CNA attempted to transfer him with the Chorus lift. On each occasion, the CNA attempted a bed-to-wheelchair transfer without a second staff member, and the resident was unable to maintain strength or balance, resulting in him being lowered to the floor. In one incident, the CNA did not lock the wheelchair, causing it to move back as the resident went to sit, contributing to the fall. Nursing notes and fall investigations documented that the resident lost strength in his upper extremities or could not maintain balance or footing while using the Chorus lift. Interviews confirmed that the resident reported falling three times because agency aides did not lock the wheelchair and only one staff member assisted him instead of two. The Director of Rehab and the DON verified that the resident always required two-staff assistance for both Chorus and mechanical lift transfers and that only one staff member had transferred him during the three incidents. The LPN on duty during all three events confirmed that each transfer was performed by a single agency CNA, that aides were expected to check the Kardex before providing care, and that one of the incidents was related to the wheelchair not being locked. Review of the facility’s falls prevention policy showed it addressed fall risk assessment and meetings but did not address monitoring to ensure that ordered interventions and care plan measures, such as required staff assistance levels, were implemented.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.