Failure to Inspect and Replace Worn Mechanical Lift Sling Results in Resident Fall and Fractures
Penalty
Summary
A resident with multiple diagnoses, including impaired mobility and generalized weakness, was dependent on staff for transfers and required the use of a mechanical lift. The resident's care plan specified the need for a mechanical lift and two-person assistance for transfers. On the day of the incident, two CNAs attempted to transfer the resident from bed to wheelchair using a mechanical lift. One CNA secured the resident's sling to the lift, while the other stood behind the wheelchair but was not within close reach of the resident. As the lift was being maneuvered, the sling's lower left strap ripped, causing the resident to fall to the floor. Both CNAs reported that the sling appeared worn out and had not been replaced since the resident's admission. The Director of Nursing confirmed that the sling's lower left and right straps were completely ripped and attributed the fall to the frayed condition of the sling. The facility's accident investigation and fall incident reports also indicated that the sling should have been inspected prior to use and that the failure to do so led to the incident. The manufacturer's instructions for the lift required that all sling attachments be checked for wear before each use, but the facility's policy did not include instructions for equipment checks before use. As a result of the fall, the resident sustained multiple fractures, including to the right hip, left pelvis, pubic bone, and lumbar vertebra, and required transfer to the hospital for evaluation and treatment. The incident was witnessed and documented in the resident's progress notes and hospital records, which detailed the injuries and the circumstances of the fall.