Failure to Ensure Safe Mechanical Lift Transfers and Fall Prevention
Penalty
Summary
The facility failed to ensure residents were properly assessed for and safely transferred using mechanical lifts, resulting in actual harm to a resident who fell from a mechanical lift sling and sustained a right tibia fracture. The resident, who had cerebral palsy and severe cognitive impairment, was dependent on staff for transfers and had a history of falls. During a transfer, the resident became restless and slid out of a mechanical lift sling that was not appropriately sized or compatible with the lift, as staff were not trained on sling selection or sizing. The medical record lacked documentation of a mechanical lift assessment for the resident, and staff interviews revealed confusion about sling types and sizing, with slings being ordered based solely on weight and not in accordance with manufacturer recommendations. Another resident was transferred using a mechanical lift without a physician's order or care plan documentation for mechanical lift use. During observation, staff failed to lock the wheelchair and the mechanical lift brakes during the transfer, and the sling was not properly positioned, with the pad extending several inches above the resident's head. These actions demonstrated a lack of adherence to safe transfer procedures and mechanical lift manufacturer guidelines. A third resident with a history of multiple falls did not have new preventive interventions implemented after each fall, despite repeated incidents and high fall risk scores. The care plan was not updated with new interventions following each fall, contrary to facility policy. Additionally, review of employee files showed a lack of documented competency evaluations for mechanical lift use among recently hired staff. These deficiencies contributed to unsafe conditions and inadequate supervision to prevent accidents.