Failure to Ensure Safe Resident Transfers and Proper Use of Mechanical Lifts and Slings
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and the correct use of assistive devices to prevent accidents, as evidenced by multiple incidents involving improper use of mechanical lifts, sit-to-stand devices, and slings. Staff did not consistently use the correct lift or sling size, and there was no established process to ensure that residents being transferred had the appropriate sling for their needs. Observations revealed that slings of various brands and sizes were stored haphazardly, with staff often selecting slings based on availability rather than suitability, and sometimes using the same sling for multiple residents. In several cases, staff were unaware of the correct sling size or type to use for specific residents, and sling sizes were not documented in care plans or assignment sheets. Several residents experienced adverse events as a result of these deficiencies. One resident fell from a Sara Steady and suffered a displaced spiral fracture of the left femur when the device was used for a transfer it was not designed for. Another resident slid off a sling that had been left under them in a wheelchair, resulting in a right humerus fracture, despite facility policy requiring slings to be removed after transfer. Additional residents were observed being transferred with slings of incorrect size or type, and some were left sitting on slings in violation of policy. Staff interviews confirmed a lack of training and knowledge regarding sling selection, use, and documentation, with some staff admitting to using whatever sling was available and not knowing the correct procedures. The facility's own policies and the manufacturers' instructions for the lift equipment require the use of the correct sling, matched by size and manufacturer, and prohibit the use of slings that are not specifically designed for the equipment in use. Despite these requirements, the facility did not maintain an organized system for sling storage, did not ensure slings were labeled or matched to residents, and did not provide adequate training or documentation for staff. The lack of a systematic process for ensuring safe transfers and proper equipment use led to multiple incidents of resident harm and created an environment with ongoing potential for more than minimal harm.