Failure to Follow Mechanical Lift Guidelines and Incomplete Fall Prevention Measures
Penalty
Summary
The facility failed to follow manufacturer guidelines during the use of a mechanical lift and sling for two residents who required assistance with transfers. In one incident, a resident who was dependent on staff for activities of daily living and had no recent history of falls was transferred using a red toileting sling. Staff did not crisscross the sling straps between the resident's legs as required by the manufacturer's instructions, resulting in the resident sliding through the sling and falling to the floor, sustaining a hip fracture and a head laceration. Staff interviews revealed that multiple nursing assistants were trained to use the sling in a manner inconsistent with manufacturer instructions, and neither the investigation nurse nor the director of nursing could state the correct method for using the sling. The care plan also lacked specific instructions on proper sling use. The facility also failed to conduct thorough fall investigations and implement individualized fall prevention interventions for several residents with a history of falls. For one resident with multiple falls, investigations were incomplete, often missing assessments of environmental factors, last toileting assistance, or staff interviews. Root causes were not consistently identified, and interventions were either not documented or not followed up. Another resident with a neurological condition and multiple falls did not have timely or adequate interventions, such as anti-roll back wheelchairs, and care plans were not updated to reflect new interventions or equipment provided. Additionally, the facility did not adhere to manufacturer requirements for routine inspection and documentation of mechanical lift slings. The operating manual specified that slings must be inspected monthly for damage and a permanent record kept, but the director of nursing confirmed that no such records were maintained. These failures in following equipment guidelines, conducting comprehensive fall investigations, and maintaining required documentation contributed to the deficiencies identified during the survey.