Failure to Use Correct Sling and Lift During Transfer Causes Resident Injury
Penalty
Summary
The facility failed to ensure the use of an appropriately sized sling and mechanical lift during resident transfers, resulting in injury to a resident who was totally dependent on staff for all transfers. During an observed transfer, staff used a blue sling with green binding, presumed to be a large size, with a [Name Brand] 450 mechanical lift, despite the resident's care plan specifying the use of an XXL blue or black sling with a [Name Brand] 600 lift. The sling used was too small, causing the resident's abdominal area to extend out the sides and exerting significant pressure on her back, arms, and legs. Staff were unable to confirm the correct sling size, and the sling's labels were missing or illegible. The resident expressed discomfort and reported that the incorrect equipment pinched her during transfers. The resident had a complex medical history, including debility, cardiorespiratory conditions, heart failure, peripheral vascular disease, anxiety, PTSD, COPD, and morbid obesity. She was also at risk for abnormal bleeding due to anticoagulant and aspirin therapy. Multiple progress notes and incident reports documented deep purple bruises on her arms and legs, which matched the shape of the sling, as well as a skin tear on her right second toe sustained when a CNA bumped her toe on a door frame during a shower transfer. The care plan had been updated previously to specify the correct sling and lift, but staff failed to follow these interventions, and there was no clear system in place for identifying or selecting the correct sling size in the storage area. Interviews with staff and review of facility policies revealed a lack of knowledge and adherence to the resident's care plan and safe lifting procedures. Staff were unsure of the correct sling size, and the storage area lacked instructions for assessing sling size. The facility's policy required ongoing assessment of residents' transfer needs and availability of appropriately sized slings, but these requirements were not met. The deficiency resulted in harm to the resident, including bruising, an injured toe, and discomfort during transfers.