Improper Use of Mechanical Lift Results in Resident Injury and Hospitalization
Penalty
Summary
The facility failed to utilize a sit to stand mechanical lift according to the manufacturer's instructions, resulting in a significant injury to a resident. The sit to stand lift was used by physical therapy staff for stand strengthening exercises, which is not an intended use per the manufacturer's guidelines. An additional strap was placed under the resident's buttocks to aid in standing, a modification not recommended by the manufacturer. During a session, the sling slipped, causing extensive bruising under the resident's left arm, left side, and across her breast. The facility did not have the correct manufacturer's manual available for the specific lift used, and staff were not following the intended use or safety instructions for the equipment. The resident involved had a complex medical history, including recent surgical repair of the left lower leg, physical deconditioning, obesity, and was prescribed a daily anticoagulant for atrial fibrillation. She was dependent on staff for all transfers and was cognitively intact. After the incident with the lift, the resident experienced pain and extensive bruising, which was reported by her family member to nursing staff. The following day, the resident suffered a syncopal episode with low blood pressure and was subsequently hospitalized. Hospital records indicated that the syncope was likely related to dehydration and acute blood loss anemia, with the bruising and bleeding into the skin under her arm contributing to her condition. She required a blood transfusion during her hospital stay. The facility also failed to investigate the cause of the bruising in a timely manner and did not complete an incident report. Multiple staff members, including the DON and Unit Manager, were unaware of the incident until after the resident was sent to the hospital. There was no written therapy plan for using the sit to stand lift for stand strengthening, and the use of the additional strap was not documented or approved. The lack of proper documentation, failure to follow manufacturer guidelines, and inadequate supervision contributed to the resident's injury and subsequent hospitalization.