Improper Sling Size Used During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to safely transfer a resident using a sit-to-stand lift. The resident, who was severely cognitively impaired and dependent on staff for transfers due to conditions including metabolic encephalopathy, muscle weakness, unsteadiness, diabetes, and multiple rib fractures, was observed being transferred with a medium-sized (yellow) sling that did not fit properly. The sling could not be secured across the resident's chest, leaving an eight-inch gap and the straps directly on the resident's bare chest. Staff interviews confirmed that the sling was too small and that the resident required a large (green) sling, as indicated by the resident's weight and facility guidelines. Further review of staff training records and personnel files showed that both CNAs involved had been trained and checked off for proper use of the sit-to-stand lift, and one had previously received verbal counseling for improper transfer technique. Facility policy and manufacturer instructions both required the use of appropriately sized slings for safe transfers. Despite these protocols, the incorrect sling size was used, and the transfer was not performed according to established procedures, resulting in a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.