Failure to Ensure Safe and Competent Use of Lifts Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure ongoing training, competency, and supervision of staff in the safe use of manual and mechanical lifts, resulting in an avoidable accident involving a resident with obesity, a history of multiple strokes, and significant functional limitations. The resident, who was care planned for manual or mechanical lift transfers, sustained a left heel bone fracture after her foot became trapped between the lift and the wheelchair during a transfer. The resident reported that staff did not place her feet correctly on the lift, and despite her attempts to alert them, her foot was not repositioned, leading to the injury. Documentation revealed that the staff member involved had not received recent or adequate training or competency evaluation for lift use, and the facility could not provide evidence of such training for other staff members assigned to similar duties. Observations and interviews indicated that staff continued to use the manual lift for the resident after the incident, and that other residents were also transferred using improper techniques, such as not ensuring feet were fully supported on the lift's footrest. Staff interviews revealed a lack of recent training, with some staff unable to demonstrate or explain proper lift use. Personnel files for multiple CNAs lacked documentation of training, in-service, or competency evaluations related to lift use. Additionally, a worn and damaged sling was observed in use during a transfer, contrary to manufacturer instructions and facility policy, which require slings to be discarded if damaged. The facility's investigation into the incident was incomplete, with missing or insufficient documentation and a lack of comprehensive staff interviews. The Director of Nursing and Administrator were unaware of the incident until days later, and the incident was not properly reported or investigated according to facility policy. Manufacturer instructions for the lift and sling emphasized the need for trained caregivers and proper equipment inspection, which were not followed. These failures created an imminent danger and substantial probability of serious harm for all residents requiring lift transfers.
Plan Of Correction
On 06/20/2025, Resident #48 was assessed by the DON/Designee; no additional issues were identified. On 6/19/2025, the Administrator reported the incident to AHCA, DCF, and law enforcement as required, with a thorough investigation initiated. On 6/30/2025, the Administrator reported the incident involving the lift to the FDA in accordance with the Safe Medical Device Act of 1990. Resident #33's lift pad was immediately taken out of service and replaced upon discovery on 6/21/2025. All current residents requiring the use of mechanical lifts have the potential to be affected. The DON/Designee audited all residents in the facility; 45 residents were identified that require the use of facility lifts. All 45 residents were assessed on 06/20/2025, with no injuries noted. The DON/Designee assessed all mechanical lift slings on 06/21/2025, to ensure all lift slings were in proper working condition, with any findings addressed as identified. The DON/ADON have reviewed, revised, and implemented new competency evaluation forms for all facility lifts to provide more specific instructions on 06/19/2025. The DON/Designee will educate Licensed Nursing Staff, Certified Nursing Assistants, Physical and Occupational Therapists regarding the proper use of all facility lifts by 07/25/2025. All new employees will receive the training as part of their new hire orientation. The DON/Designee will audit ten residents requiring mechanical lifts weekly for four weeks, then five residents requiring mechanical lifts weekly for eight weeks, to ensure the safe use of facility lifts and prevent avoidable accidents. The Administrator/Designee will submit the audit findings to the QAPI Committee monthly for review and further recommendations. Date of completion is 07/25/2025.