Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when facility staff failed to ensure safe transfers for a resident requiring maximum assistance and the use of a mechanical lift. During a transfer from a wheelchair to a shower chair, staff did not follow manufacturer instructions or facility protocol for applying and securing the sling to the mechanical lift. Instead of removing an ill-fitting sling, staff placed a second sling under the resident and attached both to the lift, which is contrary to proper procedure. The slings were not properly secured, and the staff did not verify that all straps were correctly attached before lifting the resident. As a result of these actions, the sling became unhooked from the mechanical lift during the transfer, causing the resident to fall to the floor. The resident sustained a hematoma to the back of the head and multiple fractures to the left ribs, as well as a severe compression fracture at the T12 vertebra. The resident, who had a history of spondylosis, muscle weakness, and pain, experienced significant pain and limited mobility following the incident. The incident was witnessed and described by both the resident and the staff involved, who acknowledged not following proper procedures and failing to double-check the sling attachments. Documentation and interviews confirmed that the staff involved did not adhere to the facility's policy for mechanical lift use, including ensuring the correct sling size and secure attachment. The improper use of two slings, failure to remove the incorrect sling, and lack of verification of secure connections directly led to the resident's fall and subsequent injuries. The event was identified as an Immediate Jeopardy situation due to the severity of harm caused by the unsafe transfer.
Removal Plan
- NAR's immediately removed from the floor and given education on mechanical lifts, safe transfers, and sling safety with return demonstration.
- All nursing staff education on mechanical lifts, safe transfers, and sling safety with return demonstration until all staff were trained and completed.
- Disciplinary action for NAR's involved in the incident.
- Mandatory staff meeting regarding mechanical lifts and sling safety completed.
- Audits will be completed bi-weekly and reviewed with the Quality Assurance and Performance Improvement team.