Resident Injury Due to Mechanical Lift Failure and Inadequate Inspection
Penalty
Summary
A deficiency occurred when a resident was being transferred from bed to recliner using a mechanical (Hoyer) lift that had not been properly inspected according to manufacturer instructions, nor was it identified as defective by facility staff. During the transfer, the shoulder bolt of the lift fell out, causing the resident to drop to the floor from approximately four feet in the air and land on top of the lift legs. The incident resulted in the resident complaining of pain in the right leg and right knee, and subsequent hospital evaluation revealed a displaced bicondylar fracture of the right tibia. The resident involved had multiple medical diagnoses, including cerebral palsy, heart failure, hypercapnia, hypoxemia, esophageal stenosis, and contracture of muscle in the right lower leg. The care plan indicated the resident was at risk for falls and injuries, requiring the use of a stand-up lift for transfers, and was dependent on staff for all activities of daily living. On the day of the incident, two CNAs were present during the transfer, and both reported that the lift's bolt snapped or fell out, resulting in the resident's fall. Staff interviews revealed concerns about the frequency and adequacy of lift maintenance, with one CNA stating she did not often see maintenance personnel and questioned whether the equipment was properly maintained. Review of facility records showed that monthly inspections of the lifts were documented, but the inspection prior to the incident did not specify whether the lift passed or failed, only that it was inspected. Manufacturer guidelines required monthly and semi-annual inspections of specific lift components, including bolts and mounting brackets. The failed lift was later observed to have a severely bent mounting bracket, and correspondence with the contracted medical equipment company indicated that the lift design made it prone to screws coming loose, which could lead to failure under pressure. The facility's policy was to use Hoyer lifts in accordance with professional standards, but the lack of proper inspection and failure to identify the defect led directly to the resident's injury.