Resident Injury Due to Use of Damaged Mechanical Lift Sling
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident using a mechanical lift. Two CNAs transferred a resident from a wheelchair to bed using a full body sling that had two torn attachment loops. Instead of replacing the sling, the staff attached the lift to the lower loops beneath the torn ones. During the transfer, these lower loops tore, causing the resident to fall from the lift and sustain a laceration to the back of the head, which required emergency room treatment. The resident involved had severely impaired cognition, was nonverbal most of the time, and was dependent on staff for transfers, requiring extensive assistance and use of a mechanical lift. The facility's mechanical lift policy and the manufacturer's instructions both required inspection of slings for wear prior to each use and immediate removal from service if any tearing, fraying, or wear was found. Despite these requirements, the damaged sling was used for the transfer. Interviews with staff revealed that the CNAs believed the sling was safe to use because the green loops appeared intact, even though the purple loops were broken. Laundry staff were responsible for inspecting slings for damage during washing but reported not having found any damaged slings. The restorative aide, who was assigned to conduct weekly audits of slings, was unaware of the damaged sling prior to the incident.