Failure to Remove Defective Mechanical Lift and Ensure Safe Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident dependent on staff for transfers. The facility did not remove a mechanical lift from service that was missing a critical metal clip, which is essential for securing the sling to the lift. This lift remained in use for a period of time, and staff did not identify or report the missing part prior to using the equipment for resident transfers. On the day of the incident, two CNAs attempted to transfer an 83-year-old female resident with advanced Alzheimer's dementia, severe cognitive impairment, and total dependence on staff for transfers. During the transfer, the sling was not properly secured to the lift, and the missing metal clip was not noticed by the staff. As a result, the resident fell from the sling while being lifted, striking her face on the base of the lift and sustaining an orbital fracture and other injuries. Both CNAs involved stated they had received prior in-service training on the use of the mechanical lift, but neither identified the equipment defect before use. Subsequent interviews and observations revealed that the mechanical lift with the missing metal clip continued to be used by other staff after the incident. The Operations Director and Administrator were unaware of the missing clip prior to the incident, and there was no documentation of regular equipment inspections. The manufacturer's guidelines required daily checks of the lift's sling hooks, and facility policy mandated that staff inspect equipment before use and remove any damaged equipment from service, but these procedures were not followed.