Clinical and Regulatory Best Practice – Use of Lifts to Transfer Residents

Several nursing homes throughout the past couple of years were issued deficiencies under F689 for failure to use lifts properly to prevent resident injury. Some of these deficiencies were issued at an immediate jeopardy level. This article will review the best practices for use of lifts when transferring residents.

Clinical:

When assessing a resident for appropriate transfer assistance and devices, it likely is wise to include qualified therapists such as physical or occupational therapy. However, there are times when a qualified therapist is not available and the resident may need more assistance than what is identified in their care plan. Each nursing home should have a policy that identifies individual strategies and directions for staff in these situations. A safe recommendation would be to allow staff to increase the assistance that a resident needs during a transfer and consulting a qualified therapist when decreasing the level of assistance needed is desired. An example of this would be:

• Resident A’s care plan directs staff to use a walker, gait belt, and assistance of 1 staff member during transfers and ambulation. Resident A was recently diagnosed with a urinary tract infection and staff note that the resident has not been as steady during ambulation. The nurse observes the transfer and determines for safety purposes the resident should utilize a walker, gait belt and assistance of 2 staff members during transfers and ambulation. An RN can write a nursing order for this and should follow the policies and procedures to obtain a physical therapy evaluation due to a decline in the resident’s mobility status.

Note the important aspects of the above example to maintain compliance with other regulations. A nursing order is written regarding the level of assistance. This will update the resident’s care plan and notify other staff that a change was made to the resident’s transfer and ambulation status to ensure the resident’s safety and consistency of care.

In the opposite situation though it is likely best to consult with a qualified therapist. An example of this would be:

• Resident A’s urinary tract infection has been improving and the resident appears to be gaining strength back. The CNAs ask if the resident can be returned to a 1-person assistance with transfers and ambulation. Nurses have the ability to assess in many situations, however, ensuring that residents are safe with only 1 person assisting them during transfers is not typically something that is taught in nursing school. This is why it is likely best to consult with physical therapy to determine if the resident is safe to resume the previous recommendations.

The same would hold true with changing the type of lift that is used during a transfer. Typically sit-to-stand assistive devices require a certain degree of weight bearing and both upper and lower body flexibility and strength. The device is intended to aid the resident in standing and not actually perform the entire task. If a resident is care planned to ambulate or stand-pivot transfer and becomes weak, it may be best to transition to the next device to ensure safety of the resident and the staff. This is where nursing judgment to move to a sit-to-stand lift would be appropriate. However, if the resident currently uses a full-body lift such as a Hoyer, nursing judgement is likely not the best factor in transitioning to a sit-to-stand lift. Again, this is likely best left to qualified therapists to make that recommendation.

Regulatory:

The interpretative guidance under F689 in Appendix PP of the SOM provides the following directions for assistive devices for transfers.

“Mechanical assistive devices for transfer include, but are not limited to, portable and stationary total body lifts, sit-to-stand devices, and transfer or gait belts. The resident assessment helps to determine the resident’s degree of mobility and physical impairment and the proper transfer method; for example, whether one or more caregivers or a mechanical device is needed for a safe transfer. Residents who become frightened during transfer in a mechanical lift may exhibit resistance movements that can result in avoidable accidents. Communicating with the resident and addressing the resident’s fear may reduce the risk.”

There are several factors that you should ensure are being met when using mechanical assistive devices to ensure safety and compliance. These include but are not limited to:

• The type of lift. As noted above, most sit-to-stand lift require a certain degree of weight bearing and strength to properly use. It is not appropriate to transfer a resident who is unable to bear weight, stand up straight, or assist with standing with a sit-to-stand lift. In fact, noncompliance was noted when a surveyor observed a resident essentially “dangling” by their arms/shoulders when they were unable to stand with the sit-to-stand lift. This is both unsafe for the resident as it increases the likelihood of slipping out of the lift, it increases the risk of injury to their joints such as shoulders, and it is unsafe for the staff.
• The sling. When using particular lifts, sling choice is a vital process to ensuring safety. Each lift should identify the appropriate slings and straps to use with the lift depending on the weight and functioning of the resident. You can view this example from Joerns Healthcare which provides the various slings available to use with their Hoyer loop style lift slings. The chart outlines the sling with the weight of the person being transferred and the color-coded sizing. It would be best practice to have a system which identifies the resident and what sling they must use during transfer.
  • In addition, the Joerns Hoyer Presence manual states that a frayed sling should never be used to transfer a resident. Deficiencies were noted when a frayed sling was used and during the transfer broke causing the resident to fall out of the sling.  
  • Preventative maintenance. It is important that each lift have a preventative maintenance program, including documentation of completion. The Hoyer Presence manual linked in the previous section includes a daily checklist and regular inspection and maintenance process. In the event that a lift malfunctions and causes a resident fall, the surveyor will likely ask to review the documentation on preventative maintenance.
  • Staff training and competencies. As with most practices throughout healthcare, staff training and competencies are crucial to ensuring safety. Staff competencies with lifts should include:
    • Appropriate lifts based on resident functional status and weight. Staff should ensure that they know the weight capacity of each lift to ensure they’re not transferring residents who exceed the weight capacity in the lift.
    • Slings including which sling is appropriate for lifts, particularly if you have different brands of lifts in use. This would also include the color coding to identify the size and ensuring that the size is accurate for the resident. The competencies should also ensure that staff know how to correctly place the sling when transferring a resident including how to connect it to the lift. This should be repeated for each type of sling and lift available for use.
      • If you have a sit-to-stand lift you should include any recommended additional supports (such as a belt around the legs) that should be used during transfer.
      • Staff should ensure that the sling is not frayed with each use.
• Appropriate technique of using the lift including ensuring adequate battery charge, raising and lowering, ensuring that the resident is only raised up as high as necessary to clear the bed/chair, number of staff necessary to complete the lift safely, use of the legs of the lift (such as spreading and narrowing appropriately, use of brakes when raising and lowering, and emergency procedures if the lift should stop functioning while the resident is suspended in the air. This list may not be all inclusive. Those who are developing competency checklists should review the specific lift manufacturer’s recommendations to ensure an exclusive list.
• Procedures for charging and replacing batteries for the lifts.