Failure to Assess and Use Proper Sling During Mechanical Lift Transfer Results in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure resident safety during a mechanical lift transfer by not assessing and using the appropriate sling, and by not inspecting the sling for signs of wear or damage prior to use. A resident, who was cognitively intact and recently admitted with a diagnosis including anxiety disorder, was transferred using a sling that was not approved for transfers and was in poor condition. The sling was obtained from the laundry, was not on the facility's audit list, and was not provided by the facility's lift company. During the transfer, staff used a shower sling instead of a transfer sling, despite concerns raised by a CNA. The CNA consulted with an RN and an LPN, who allowed the use of the incorrect sling for that instance. The sling appeared old, faded, and had frayed straps, but was still used. The resident fell approximately three feet to the floor when the sling's straps broke, resulting in a skin abrasion and an L1 compression fracture. Interviews with staff confirmed that the resident had not been assessed for lift use, the sling was not inspected for damage, and the correct sling size was not determined. Staff involved acknowledged that proper procedures were not followed, and the sling used was in poor condition and not intended for transfers. Documentation showed that staff had previously been trained and checked off on proper sling use, but these protocols were not followed during the incident.