Failure to Ensure Safe Resident Transfers and Proper Sling Use
Penalty
Summary
The facility failed to provide safe transfers for three residents, resulting in accident hazards and inadequate supervision. One resident, with a history of stroke, heart failure, dementia, and on anticoagulation therapy, was dependent on staff for transfers and required a two-person assist with a stand lift as per her care plan. However, a CNA attempted to transfer her alone using the incorrect full body lift instead of the stand lift, leading to the resident falling from the lift, sustaining a head laceration that required staples, and being sent to the emergency department. Subsequent clinical notes documented extensive bruising and pain, with medical evaluations revealing hematomas and ecchymosis over multiple body areas. Observations and interviews indicated improper placement in the lift and ill-fitting slings contributed to repeated injuries during transfers. For another resident with atrial fibrillation, dementia, and multiple sclerosis, staff used a full body lift with an XXL sling for transfers, despite the resident's weight being below the recommended range for that sling size. Staff were observed to be unaware of the correct sling sizing, and the facility's lift sizing chart was not consistently referenced. The Assistant Director of Nursing confirmed that the wrong sling size was used for this resident, and staff required further education on proper sling selection based on weight and body size. A third resident, with coronary artery disease and severe cognitive impairment, was also transferred using an XXL sling, which was not appropriate for her weight. The facility's policy required individualized assessment for transfer assistance, including proper sling size and fit, but staff relied on judgment rather than established guidelines. The color-coded sling system and sizing chart were not consistently followed, leading to the use of slings that did not fit residents properly, increasing the risk of injury during transfers.