Failure to Maintain and Replace Mechanical Lift Sling Leads to Resident Fall
Penalty
Summary
The facility failed to follow the manufacturer's maintenance recommendations for a mechanical lift-sling transferring device, resulting in the use of worn and unsafe equipment. A resident with multiple diagnoses, including impaired mobility and generalized weakness, was dependent on staff and a mechanical lift for transfers. On the day of the incident, two CNAs attempted to transfer the resident using a mechanical lift when the sling's lower left strap ripped, causing the resident to fall to the floor. Both CNAs reported that the sling was old, worn out from overuse, and had not been replaced since the resident's admission. The Director of Nursing confirmed that the sling's straps were completely ripped and that the sling appeared worn out from overuse. The facility did not have a policy for maintaining lift sling equipment, and the DON was unaware of the manufacturer's service life recommendations. The resident's care plan indicated a risk for falls and required the use of a mechanical lift with staff assistance. Documentation from the accident investigation and fall incident reports confirmed that the fall occurred because the sling broke, and that the sling should have been inspected prior to use. The manufacturer's guidelines specified that slings should be inspected after each laundering and discarded if found to be bleached, torn, cut, frayed, or broken, with an expected service life of thirteen months. The facility's policy required providing an environment free from hazards and ensuring the use of safe assistive devices, but this was not followed in the case of the mechanical lift sling.