Failure to Ensure Safe Use of Mechanical Lifts and Individualized Fall Prevention
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and appropriate assistive devices to prevent accidents, specifically in the use of mechanical lifts and slings for transfers. For one resident, staff used a sling brought in by the family without assessing its appropriateness for the resident's size, weight, or compatibility with the facility's Hoyer lift. During a transfer, the resident slid out of the unassessed sling and fell, sustaining a subdural hematoma and a laceration to the back of the head, which required hospital treatment and staples. Staff interviews revealed that they were unfamiliar with the manufacturer's recommendations for sling use and did not verify sling compatibility or sizing before use. There was no system in place to ensure that slings were assigned, labeled, or matched to individual residents, and staff often assumed that any sling found in a resident's room was appropriate for use. Another resident experienced multiple falls, including one resulting in multiple rib fractures after being left unattended during personal hygiene. The facility did not analyze the details of each fall or develop an individualized, comprehensive plan of care to prevent future incidents. Despite the resident's known incontinence and impulsivity, the facility did not complete a voiding pattern assessment or review the need for increased supervision, even after staff suggested it post-fall. The lack of individualized assessment and care planning contributed to repeated accidents and injuries. Observations during the survey found that slings were not consistently labeled with resident names or sizes, and staff frequently used slings interchangeably among residents without verifying appropriateness. Staff relied on assumptions or visual cues rather than documented assessments to select slings, and there was no clear documentation or quick-reference information available to guide staff in choosing the correct sling for each resident. The facility's failure to implement a system for assessing, assigning, and documenting appropriate sling use, as well as its failure to analyze and address fall risks, resulted in actual harm to residents and created a pattern of unsafe practices.