Failure to Ensure Competent and Safe Use of Mechanical Lift During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff, specifically a CNA, had appropriate competencies and skill sets to safely use a mechanical lift for resident transfers. A resident with Alzheimer’s disease, expressive language disorder, osteoporosis, and significant ADL self-care and mobility deficits was care planned and assessed as dependent for all ADLs and requiring a Hoyer lift with two staff for transfers. On the observed date, two CNAs entered the resident’s room to transfer her using a mechanical lift, applied gloves, positioned the lift under the bed, and attached the sling that was already under the resident to the lift. During the transfer, CNA B did not lock the wheels of the mechanical lift before raising the resident from the bed. After lifting 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 came 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 and detached the sling. CNA B later stated she knew she should have locked the wheels but claimed the wheel lock was broken and that this lift was typically the only one available because the other battery-operated lifts were never fully charged. CNA B reported she had been trained in mechanical lift use in the past, had informed the DON that the lift’s wheels would not lock, and that the lift had been in this condition since she started working at the facility 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. The DON stated that two staff were required for mechanical lift use, that wheels should be locked when positioning, and that staff had competency check-offs on hire, as needed, and annually; however, she could not locate a mechanical lift competency checklist for CNA A and record review showed CNA B had no skills check-off on hire and none was provided before survey exit. Facility policy required facility- and resident-specific competency evaluations upon hire, annually, and as deemed necessary based on the facility assessment.
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