Failure to Ensure CNA Competency in Mechanical Lift Sling Selection Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that five certified nurse assistants (CNAs) were trained and competent in the use of the mechanical lift device, specifically in selecting and using the correct sling size for residents, as required by facility policy and the manufacturer's instructions. This deficiency was identified through observation, interviews, and record review, which revealed that CNAs were not provided with adequate in-service training or competency assessments regarding the different sling sizes and their appropriate use based on resident assessments and weight. Instead, CNAs learned to use the mechanical lift and slings informally from coworkers, and there was a widespread lack of awareness among staff, including laundry and maintenance personnel, about the existence of different sling sizes and their significance. As a result of this lack of training and competency, two CNAs used a small sling instead of the required full body, extra-large sling to transfer a resident with significant mobility impairments, including hemiplegia, hemiparesis, muscle weakness, and contractures. During the transfer, the resident slipped out of the incorrectly sized sling and fell, sustaining a large hematoma on the back of the head, pain, and nausea/vomiting, which necessitated transfer to an acute care hospital for evaluation and treatment. The incident was documented in the resident's progress notes, care conference records, and hospital emergency department records, all of which confirmed the use of the wrong sling size and the resulting injury. Further investigation revealed that the facility's competency checklists for mechanical lift use did not include assessment or demonstration of selecting the correct sling size and capacity for residents. Interviews with CNAs, laundry staff, and the maintenance director confirmed that staff were unaware of the different sling sizes and had not received training on this aspect of resident care. The Director of Staff Development also acknowledged that no training or skills competencies had been conducted on sling size selection for the mechanical lift, and the Director of Nursing confirmed that the competency checklist was incomplete in this regard.