Failure to Remove Worn and Faded Mechanical Lift Slings from Service
Penalty
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible for three residents who required mechanical lift assistance for transfers. Observations revealed that the mechanical lift slings used for these residents had faded and light-colored straps, indicating wear and possible improper laundering. The colored connection tabs on the slings, which are essential for safe use, were no longer bright and had become uniformly light blue, rather than their original distinct colors. Record reviews showed that all three residents had significant physical and/or cognitive impairments, requiring total or maximal assistance with transfers using mechanical lifts. The facility's policy and manufacturer guidelines both required that slings be inspected for damage, including rips, tears, fraying, and color fading, and that any slings showing such signs be immediately removed from service. However, interviews with staff revealed a lack of awareness regarding the need to inspect for color fading, with some staff only checking for physical damage such as rips or tears. Laundry and nursing staff were both responsible for inspecting slings, but there was inconsistency in understanding and following the inspection protocols, particularly regarding faded straps. The deficiency was further evidenced by direct observations of residents sitting in wheelchairs with faded slings in use, and by staff interviews confirming that faded slings were not previously recognized as a hazard. The facility's own policy and the manufacturer's instructions explicitly stated that faded or improperly laundered slings are unsafe and should be removed from use, but this was not consistently implemented, resulting in the continued use of worn and faded slings for resident transfers.