Failure to Provide Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, significant physical dependencies, and a high body weight was not provided with safe and appropriate mechanical lift transfers. The resident, who was dependent on staff for all activities of daily living and had diagnoses including non-Alzheimer's dementia, anxiety disorder, aphasia, diabetes, and arthritis, required the use of a mechanical lift for transfers. On the day of the incident, staff used a mechanical sling that was too small for the resident's weight, as indicated by the color-coded system provided by the sling manufacturer. The purple sling used was rated for 125-200 pounds, while the resident weighed over 318 pounds and required a blue or black sling rated for higher weights. Staff involved in the transfer were unaware of the correct sling size, and the closet only contained the incorrect size at the time. Additionally, the tags on the slings were worn and difficult to read, and there was no sizing chart available in the storage area to guide staff in selecting the appropriate sling. During the transfer, the sling became dislodged from the mechanical lift at the resident's left shoulder, causing the resident to fall from a height of at least four feet. Staff interviews revealed that one staff member let go of the resident to prepare the bed, and the other was operating the lift, resulting in the resident falling out of the sling. The incident report and staff statements confirmed that the wrong size sling was used and that staff did not verify the compatibility or condition of the sling prior to use. The facility's investigation also found that the slings in use were not approved for use with the specific brand of mechanical lift, and the manufacturer had not tested or approved the combination of sling and lift used during the incident. Following the fall, the resident reported severe back pain and was sent to the emergency room, where imaging revealed a mildly depressed T12 compression fracture. The facility's policies required the use of appropriate equipment and supervision to prevent accidents, but these were not followed in this case. The lack of proper sling availability, absence of clear guidance for staff, and failure to ensure equipment compatibility directly contributed to the resident's fall and injury.