Failure to Follow Lift Transfer Protocols Results in Resident Fall and Serious Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure proper practices were followed during a mechanical lift transfer, resulting in a resident falling from the lift. The resident, who had multiple diagnoses including schizoaffective disorder, bipolar disorder, diabetes mellitus, muscle wasting with atrophy, and Parkinson's disease, was dependent on staff for transfers and required a two-person assist with a specific size and color of sling as indicated on her care plan and wall care sheet. Despite these clear instructions, staff used a sling that was the wrong size and did not attach the sling loops correctly to the lift, with one strap being hooked in a different loop position than the others. On the day of the incident, two CNAs were responsible for transferring the resident using the mechanical lift. The sling used was a large, blue-trimmed pad instead of the required medium, red-trimmed pad. The top right strap of the sling was attached to a higher notch, while the other three straps were attached to the lowest level, closest to the pad. Staff involved in the transfer admitted to not checking the care sheet for the correct sling size and instead used the sling that was already in the room. Both CNAs had previously received training and check-offs on proper lift use, sling size selection, and correct attachment procedures, but failed to follow these protocols during the transfer. As a result of these failures, the resident fell from the lift, sustaining a complete displacement fracture of the proximal left femur and a subarachnoid hemorrhage. The incident was witnessed by other staff, and immediate first aid was provided before the resident was sent to the hospital. The facility's investigation confirmed that the wrong sling size was used and the sling was not properly attached, directly leading to the resident's fall and injuries.
Removal Plan
- The administrative team in-serviced all CNAs and nurses on proper lift technique and correct sling use.
- The administrative nursing team checked-off all CNAs and nurses on the lift and slings, using return demonstration technique.
- All lifts were inspected by the assistant administrators to ensure they were in safe working order.
- S3 CNA and S4 CNA received individual counseling and in-service. Skills check-off was completed, with follow-up questions, to ensure complete understanding.
- S3 CNA and S4 CNA were to ensure a nurse was present during any transfer of a resident with a lift. The nurse completed a check-off sheet, documenting use of the correct sling size and correct connection of the sling to the lift.
- S2 ADON ensured all residents requiring use of the Vander-Lift had the correct sling size indicated on the care sheet in their room. The size/color of sling to be used was added to each order for the Vander-Lift.
- The housekeeping supervisor checked all the slings in the building, ensuring they were not frayed or torn, and were in good working condition.
- The medical equipment company inspected all lifts in the facility to ensure they were in safe use.
- S1 ADM provided an in-service to all Laundry staff regarding proper laundering of lift slings.
- The Assistant Administrator ensured all resident rooms provided enough space for safe transfer with a lift.
- The DON or designee will monitor a random sample of residents being transferred with a lift to ensure the correct procedure was followed. This monitor will be completed 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed.
- The DON or designee will monitor, ensuring any lift sling in a resident's room was the correct size for the resident. This monitor will be completed on a random sample of residents with lift orders 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed.
- Administration was responsible for oversight of all the implemented actions, which would be reviewed during the weekly Quality Meeting for 6 weeks.