Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure safe transfers for a resident using a full body mechanical lift. Two nursing assistants were involved in transferring a resident who was dependent on staff for all transfers and had significant medical conditions, including a recent femur fracture, artificial hip joint, hemiplegia, and hemiparesis. During the transfer, the nursing assistants did not follow the manufacturer's recommendations for the lift and did not properly attach the sling, specifically using different length black loops on each side of the sling, which caused slack and led to the sling detaching from the lift arm. The resident slipped out of the improperly secured sling and fell from an elevated height, striking his head on the ground. The incident resulted in a new fracture of the right femur, requiring hospitalization and surgical intervention. Documentation and interviews confirmed that the nursing assistants were aware that the same length loops should be used but failed to ensure this during the transfer. Additionally, they had not received specific training on the type of sling used for this resident, which had two sets of black loops that could be easily confused. The facility's policies required staff to use appropriate techniques and processes when utilizing mechanical lifts and to conduct root cause analyses following falls. However, the staff involved did not adhere to these protocols, and the lack of specific training on the sling contributed to the incident. The root cause was identified as the use of different length loops, which led to the release of tension and the resident's fall.
Removal Plan
- R1 will be reassessed on return from the hospital for proper sling size and care plan updated.
- Sling and lift used for R1's transfer was removed from use until inspected and found to be free of malfunction.
- NA-A and NA-B had return demonstration competency testing done for safe lifting using the mechanical lift.
- The facility reviewed their policy and procedure for safe mechanical lift transfers and developed a plan to ensure identification via color coding the sling loops to ensure the correct one being used. Policy will be adjusted after mechanical lift representative reviews policy, if needed.
- All residents utilizing similar slings like R1 have had the proper sling to use marked with the colored tape to identify the same loops.
- All residents who utilized the mechanical lifts had slings inspected, care plans reviewed to ensure the proper sling size in the care plan.
- The facility began re-education with return demonstration, to nursing staff on manufacturer's recommendations of using the full body mechanical lift to include checking the straps for tension and using proper sling size according to the care plan and will be having mechanical lift representative provide education to all of the nursing staff.