Failure to Ensure Safe Mechanical Lift Operation and Sling Use During Resident Transfers
Penalty
Summary
The facility failed to ensure the safe operation of a full body mechanical lift and the use of appropriate slings during resident transfers, resulting in a serious incident. Staff used a mechanical lift with a spreader bar that had a gap of over 1 centimeter between the hook cradle and the rubber stopper, which was not identified prior to use. During a transfer, staff did not clear a resident's bottom over a bed wedge cushion, causing the lift sling strap to lift off the spreader bar hook. This led to the resident falling to the floor and sustaining a 3-4 centimeter gash to the back of the head, which required hospitalization for subdural and intraventricular hemorrhage. The resident involved had significant cognitive and physical impairments, including severe memory problems, inability to make daily decisions, and dependence on staff for transfers. The care plan and Kardex directed the use of a full body mechanical lift with two staff but did not specify the type or size of sling to be used. Staff interviews revealed a lack of knowledge regarding appropriate sling selection, with staff often choosing sling size by visual estimation rather than by specific guidance. There was also confusion about which slings were compatible with which lifts, and some slings in use were not recommended by the lift manufacturer. Multiple staff reported that issues with sling straps coming off the lift hooks had been observed previously and communicated to management, but no action was taken to address these concerns. Maintenance staff had not received adequate training on inspecting the lifts, and inspection logs were incomplete or lacked documentation of when equipment was removed from service. Observations also showed that staff did not consistently follow safe practices, such as ensuring the lift legs were in the wide position during transfers. The combination of equipment malfunction, lack of clear procedures, and insufficient staff training directly contributed to the incident and the resulting harm.