Improper Mechanical Lift Use Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident, who required total assistance with transfers using a full body mechanical lift, fell from the lift due to improper attachment of the sling. The resident had intact cognition and medical diagnoses including colon cancer, a previous left humerus fracture, and hemiplegia. The care plan specified the use of a mechanical lift with a particular sling size, and the transfer was being performed by two staff members from the bed to a shower chair. During the transfer, one of the sling's straps was not attached to the lift according to the manufacturer's instructions. Specifically, the lower right strap was placed at the top of the hook instead of the lower part, resulting in the strap coming off during the transfer. This caused the resident to fall approximately three feet to the floor, leading to an acute left femur fracture that required surgical intervention. The incident was witnessed on video by a family member, who confirmed the improper attachment of the sling. Interviews with staff involved in the transfer revealed that they believed they knew the correct procedure for attaching the sling, but failed to secure it properly. The manufacturer’s representative confirmed that improper attachment could result in sling detachment and injury. The facility’s policy and the manufacturer’s instructions both required that sling loops be secured at the bottom of the hooks, which was not followed in this incident.
Removal Plan
- Suspend staff involved in the incident pending investigation.
- Remove the lift and sling from use.
- Educate staff on identifying sling size, locating resident's sling size, attaching the sling to the lift, and actions to take if the care plan does not identify sling size or if the proper sling size is not available.
- Competency test all nursing staff on use of the full mechanical lift.
- Require staff who have not completed education or competency test to complete both at the start of their next scheduled shift.