Failure to Inspect Mechanical Lift Sling Results in Resident Fall
Penalty
Summary
Facility staff failed to follow established policies and procedures for the safe use of mechanical lifts, resulting in an incident where a resident fell during a transfer. The staff did not properly inspect the lift sling for signs of wear or damage prior to use, as required by both facility policy and manufacturer instructions. During the transfer, the strap on the sling broke, causing the resident to fall from the sling and hit their head on a recliner, resulting in two bumps on the back of the head. The incident occurred while the resident was being assisted by a CNA and an RN using a Hoyer lift. The resident involved had multiple medical conditions, including osteoporosis, osteoarthritis, muscle weakness, and was on anticoagulant therapy for atrial fibrillation, increasing the risk of injury from falls. The care plan specified the use of a mechanical lift for transfers when the resident was fatigued or in pain, and interventions were in place to address fall risk. Despite these precautions, the failure to inspect the sling prior to use directly contributed to the accident. Interviews and record reviews revealed that the facility's practice for sling maintenance and inspection was inconsistent. The Maintenance Director reported monthly checks of slings, but also noted that slings had been dried in a dryer against manufacturer recommendations, which could compromise sling integrity. Staff statements indicated that while some were trained to inspect slings before use, there was no documented in-service training on sling inspection prior to the incident. The sling involved in the incident had no service date, and the broken strap showed evidence of a cut or fraying that should have led to its removal from service.