Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that sling straps were properly connected to a hanger bar before transferring a resident using an electric mechanical lift, resulting in a resident falling from the lift sling onto the floor and sustaining significant injuries. During the transfer from bed to wheelchair, two CNAs were involved in applying the sling and operating the lift. One CNA moved the lift while the other guided the resident, but the resident rolled out of the sling and fell. Upon assessment, it was found that one of the sling loops had come off the lift hook, and the nurse on duty observed the loop hanging off the swing bar. The resident suffered a contusion, bleeding from the nose, fractured ribs, a fractured left arm, and a lacerated spleen, requiring hospital admission. The resident involved had multiple medical conditions, including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, and was fully dependent on staff for mobility and transfers. The care plan specified the use of a green full body sling with two staff for all transfers, but the lift-transfer evaluation indicated a blue (extra large) sling was required. The care plan and Kardex had not been updated to reflect this change. During interviews, staff could not confirm how many times the sling loops were checked before the transfer, and one CNA admitted that the straps were not double-checked on the day of the incident. Review of facility policies and manufacturer instructions revealed that staff are required to check that all sling straps are properly connected to the hanger bar before and after elevating the resident, and to lower the resident if any attachments are not secure. Both CNAs involved had completed required training and demonstrated competency in lift use. The lift and sling were found to be in good working order, with no broken parts, and had passed recent maintenance inspections. Despite these measures, the failure to ensure all sling loops were properly secured directly led to the resident's fall and subsequent injuries.