State Findings:
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, staff interviews, and review of the facility policy titled, Operating Procedures; Lift 3.100.00 it was determined that the facility failed to ensure that one of six residents (R#1) was transferred via two person assist while using a sit to stand during a transfer from the resident’s wheelchair to bed. Actual harm was identified on 11/1/18 when R#1 slipped during transfer and suffered a closed [MEDICAL CONDITION] end of her left femur.
During an interview with CNA AA on 3/12/19 at 3:25 p.m., revealed that she had used the sit to stand lift by herself to transfer the resident from the wheelchair to the bed. As she was lifting the resident from the wheelchair, the resident started leaning to the right and was sliding off the wheelchair, so CNA AA slowly lowered the resident to the floor. CNA AA stated that it looked like the resident’s right knee had come out of the device that holds the knees in place.
During an interview with the Director of Nursing (DON) on 3/13/19 at 9:40 a.m., revealed that she expected her staff to have two people present when using a lift including the sit to stand lift. She stated it was just better to have an extra person there in case something happened. The DON stated that she also makes sure new employees are familiar with the lifts and tells them to have two people present when using the lifts. The DON stated she felt if there had been another person present when CNA AA transferred R#1, it might have prevented the accident.
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