Failure to Use Required Safety Straps During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was transferred using a sit-to-stand mechanical lift without the required safety straps, contrary to the manufacturer's instructions. The incident took place when the resident's right arm gave out during the transfer, causing the waist belt to pop off and resulting in the resident being lowered to the floor. The safety straps on the lift were not used on the resident's waist or legs during the transfer, and this omission was confirmed by both the facility's internal investigation and staff interviews. The resident initially refused medical treatment but later agreed to an x-ray, which showed no injury. The resident involved had a history of stroke resulting in no use of his left arm and leg, but was able to bear weight with a brace on his left leg. Documentation in the electronic medical record (EMR) indicated that the resident had previously refused to use the chest or leg straps during transfers, despite being educated on their necessity for safety. Staff interviews revealed that some staff had not experienced refusals from the resident, while others confirmed his refusals and described him as particular and sometimes verbally abusive regarding his care. The care plan and EMR lacked clear documentation about the resident's fall risk, transfer method, or history of falls. The facility relied on a working care plan and a hall sheet for daily care instructions, but the EMR care plan did not include specific transfer information. The manufacturer's instructions for the lift required the safety strap to be securely fastened around the patient's torso, and the use of a shin strap if necessary. The failure to follow these instructions and ensure the use of safety straps during the transfer directly led to the incident.