Failure to Ensure Proper Sling Use and Supervision During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents who required mechanical lift transfers were provided with the correct size sling and adequate supervision, resulting in accidents and potential hazards. In one incident, two CNAs used a small sling instead of the required extra-large full body sling to transfer a resident with hemiplegia and other mobility impairments. Despite the resident expressing concern that the sling was too tight, the CNAs proceeded with the transfer, during which the resident slipped out of the sling, fell, and sustained a large hematoma on the back of the head, as well as nausea and vomiting. The resident was transferred to the hospital for evaluation and treatment following the fall. The investigation revealed that the CNAs involved were not aware of the different sling sizes and had not received specific training or competency evaluation regarding the selection and use of the correct sling size for mechanical lift transfers. Interviews with staff, including laundry and housekeeping personnel, indicated a general lack of knowledge about sling sizing, with slings being distributed without regard to size or resident-specific needs. The facility's competency checklist for mechanical lift use did not include assessment of sling size or review of resident assessments for recommended sling size based on weight. In a separate incident, a CNA transferred another resident, who was dependent for all transfers and required a mechanical lift with a medium-sized sling, without the required assistance of a second staff member. The CNA acknowledged being aware of the two-person policy but proceeded alone because other staff were busy. This action was observed by the ADON, who confirmed it was against facility policy and placed the resident at risk for falls and injury. The facility's policy and the manufacturer's instructions both required proper sling sizing and two-person assistance for safe mechanical lift transfers, but these protocols were not consistently followed.