Failure to Secure Mechanical Lift Sling Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that a mechanical lift sling was properly secured and free from entanglement hazards after transferring a resident to a wheelchair. The resident, who had moderately impaired cognition and required maximum assistance with mobility, was dependent on staff for all transfers and used a full-body mechanical lift. The care plan specified the use of a particular sling and required that straps be secured in the wheelchair according to the resident's preference. However, after an outing, a lower sling strap was left unsecured and became caught in the front wheel of the resident's wheelchair, pulling the resident's left leg backward and tightly against the chair. Multiple staff members were involved in the incident. The Activity Director was pushing the resident back to her room when the strap became entangled in the wheelchair wheel. A nursing assistant at the nurses' station heard the resident express pain and observed the entanglement, immediately intervening to stop the wheelchair and loosen the strap. At the time, neither the nursing assistant nor the LPN who was notified observed any visible injury, redness, or swelling on the resident's leg. The incident was reported to the LPN, but no documentation was made in the resident's record at that time. Later, the resident experienced increased pain and developed a traumatic hematoma on her left leg, which required hospitalization, surgical intervention, and a blood transfusion due to a significant drop in hemoglobin. The facility's internal investigation confirmed that the leg strap of the lift sling had not been properly secured or tucked away after the transfer, leading to the entanglement and subsequent injury. Staff interviews corroborated that the sling straps should have been tucked back and under the resident to prevent such incidents.