Improper Use of Mechanical Lift During Dependent Resident Transfer
Penalty
Summary
The facility failed to ensure a resident’s environment remained as free of accident hazards as possible when staff did not properly and safely use a mechanical lift during transfers. The resident was an elderly woman with Alzheimer’s disease, expressive language disorder, osteoporosis, and documented ADL self-care performance deficits and limitations in physical mobility. Her care plan and MDS indicated she was dependent on staff for all ADLs, including transfers, and required a Hoyer lift with two staff for transfers. During an observed transfer, two CNAs applied the sling and used the mechanical lift to move the resident from bed to wheelchair. CNA B widened the base and placed the lift under the bed, but did not lock the wheels before lifting the resident. After elevating the resident, CNA B closed the legs of the lift, moved it to the wheelchair, then widened the base again and began lowering the resident. As the resident was being lowered, one of the lift’s wheels lifted off the floor, and CNA B stood on the lift to force the wheel back into contact with the floor while CNA A guided the resident into the wheelchair. In interviews, CNA B stated she knew she should have locked the wheels but claimed the wheel lock was broken and that this lift was usually the only one available because the other two battery-operated lifts were never fully charged. She reported she had informed the DON that the lift’s wheels could not be locked and that the lift had been in this condition since she started working there about three months earlier. She also stated she had previously refused to use the lift but felt she was treated as lazy when she did so. CNA A reported she did not notice that the wheels were not locked and was not aware of any problem with the locks. The DON stated that two staff were required for mechanical lift use, that residents should be secured with one staff operating the lift and one guiding it, and that the wheels should be locked once in position. The Administrator stated staff should not use mechanical lifts if the locks did not work and should report issues to nursing, Maintenance, or the DON. The facility’s “Safe Lifting and Movement of Residents” policy required staff to be trained in the use of mechanical lifting devices and to be observed for competency and adherence to policies and procedures regarding safe equipment use.
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