Failure to Ensure Safe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident who required a mechanical lift and two-person assistance for transfers. The resident, who was dependent on staff for activities of daily living due to impairments in both upper and lower extremities, was being transferred from a wheelchair to a bed. During the transfer, two CNAs were present; one positioned the sling straps over the front hooks, but the other failed to properly secure the back sling straps to the lift. As the lift was operated and the resident was raised approximately two feet, the unsecured straps led to the resident sliding forward and falling from the sling to the floor. The incident resulted in the resident sustaining a head laceration and crying out in pain, with blood observed on the face and floor. The LPN on duty was notified and, upon assessment, called for emergency medical assistance. The resident was subsequently transferred to a hospital for evaluation and treatment and did not return to the facility. The facility's investigation confirmed that the mechanical lift and sling were not faulty, and the failure was attributed to staff not following the standard operating procedure for mechanical lift transfers. The resident's care plan specified the use of a mechanical lift with two-person assistance for all transfers due to a history of multiple falls and fractures. Facility policy and manufacturer instructions both required that all sling straps be properly secured before lifting a resident. Staff interviews confirmed that the standard practice was to have two staff members present and all four straps hooked appropriately to prevent such incidents. The failure to adhere to these procedures directly led to the resident's fall and injury.