Failure to Assess and Document Proper Sling Size for Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility did not assess residents for the safe use of the EZ sit to stand lift for five residents, nor did it have a procedure in place to assess and document the appropriate size and fit of the EZ Way Smart Stand mechanical lift slings for each resident. Certified Nursing Assistants (CNAs) were left to determine sling size based on their own judgment, without guidance from care plans or CNA care guides, and without documented assessments of residents' torso circumference as required by manufacturer guidelines. Multiple residents with significant mobility impairments, including those with a history of stroke, hemiplegia, Parkinson's disease, and other conditions requiring substantial assistance with transfers, were observed being transferred using the EZ sit to stand lift. In all cases, there was no documentation or care plan specifying the correct sling size, and no evidence that an assessment of torso circumference had been completed. During observations, CNAs selected slings based on availability and their perception of resident size, sometimes discussing among themselves which sling to use. In one instance, a resident was observed hanging from her armpits during a transfer, indicating improper fit or use of the sling. Interviews with staff, including CNAs, an Occupational Therapist, an LPN, and the Director of Nursing, revealed a lack of clarity and responsibility regarding who was supposed to determine and document the correct sling size for each resident. The Director of Nursing acknowledged that sling size was not listed on any care guide and was unsure who was responsible for assigning sling sizes. Inventory checks showed limited availability of sling sizes, and staff reported that slings were not kept in residents' rooms and would need to be washed before reuse, potentially delaying care. The lack of assessment, documentation, and clear procedures led to inconsistent and potentially unsafe use of mechanical lift slings for residents requiring assistance with transfers.