Failure to Train Staff and Implement Sling Sizing Guidelines for Mechanical Lifts
Penalty
Summary
The facility failed to provide adequate training and maintain effective procedures regarding the sizing and use of full body lift slings for residents requiring mechanical transfers. Observations and staff interviews revealed that staff members selected slings based on personal preference rather than resident-specific sizing guidelines. Sling tags were found to be illegible, and there was no system in place to distinguish or assign sling sizes to individual residents. The care plans for residents dependent on full body lifts did not specify the appropriate sling size, and staff were unaware of the correct sizing requirements. One resident with a history of stroke and Alzheimer's disease, who was dependent on two staff for all transfers using a full body lift, was transferred using a cloth blue full body sling without clear identification of the correct size. Staff involved in the transfer, including a new CNA and a business office manager acting as a CNA, used the sling without reference to any sizing protocol. The Assistant Director of Nursing confirmed the lack of a system for identifying sling sizes and acknowledged that staff were using slings according to their own preferences. Another resident with severe cognitive impairment and total dependence on staff experienced a fall from a Hoyer lift during a transfer. Both CNAs involved in the incident reported that the resident grabbed the Hoyer straps, causing the sling to shift and the resident to fall forward. Staff interviews indicated that slings were used interchangeably, with no consistent method for selecting the appropriate size or type. Concerns about the slipperiness of certain slings had been raised by staff, but there was no evidence of a standardized process for addressing these issues or ensuring proper sling selection for each resident.