Resident Fall Due to Improperly Secured Mechanical Lift Sling
Penalty
Summary
A deficiency occurred when a resident with paraplegia, who required extensive assistance and the use of a mechanical lift for transfers, sustained a fall during a transfer from bed to wheelchair. The incident happened when staff were using a Hoyer lift and one of the sling straps slipped off or became unattached, causing the resident to fall from a height. The resident's leg struck the mechanical lift during the fall, resulting in a left femur fracture and a nondisplaced left sacral alar fracture, which required hospitalization and surgical intervention. Record reviews revealed that the resident was cognitively intact and dependent on two staff for transfers, as documented in the care plan and Minimum Data Set (MDS) assessment. The facility's policy on mechanical lifts required staff to securely attach sling straps according to the manufacturer's instructions and double-check their security before lifting the resident. However, staff interviews and progress notes confirmed that the sling was not properly secured, leading to the strap slipping off during the transfer. Both staff involved in the transfer and the resident confirmed that the fall occurred due to the strap becoming unattached while the resident was suspended in the lift. Further investigation showed that facility leadership, including the Director of Nursing Services (DNS) and the Administrator, were not present during the incident and could not provide evidence that the transfer was performed safely or that the resident was interviewed for a detailed account of the event. The lack of proper securing of the sling and failure to ensure adherence to established transfer protocols directly led to the resident's fall and subsequent injury.