Failure to Use Required Two-Person Assistance for Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and safe use of a mechanical lift for a resident who required assistance from two staff members for all transfers. The resident was an adult male with a primary diagnosis of cerebral infarction and secondary diagnoses including bipolar disorder, encephalopathy, cognitive and emotional deficits following cerebral infarction, and hemiplegia/hemiparesis. His Interim Payment MDS showed a BIMS score of 13, indicating he was cognitively intact, and Section GG documented that he was totally dependent on staff for bed mobility and transfers, requiring assistance from two or more staff for sitting to lying, lying to sitting, sit-to-stand, chair/bed transfers, and toilet transfers. His care plan identified him as at high risk for falls and documented actual falls on two consecutive days with discoloration to his left hand. On the survey date, a CNA was observed transferring this resident alone from his wheelchair to his bed using a mechanical lift, while the Administrator was present and stated he was observing the activity to ensure safety. The resident reported that it did not bother him that only one staff member used the lift, but did not indicate how often this occurred. The CNA stated she had been properly trained, knew that mechanical lifts required two staff for safety, and acknowledged that she transferred the resident alone because he became upset if his preferences were not followed and no other staff were immediately available. An LVN on the same shift stated that staff were not supposed to use mechanical lifts alone, that the charge nurse was responsible for ensuring proper use, and that she was unaware the CNA was using the lift by herself. The Administrator stated his expectation was that mechanical lifts be used with two or more staff, and the facility’s undated “Lifting Machine, using a Mechanical Level II” policy specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift.
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