Mechanical Lift Sling Failure During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident, who was totally dependent on staff for transfers and had a history of stroke and chronic pain, was being transferred using a mechanical lift. During the transfer, one of the four straps on the lift sling broke at the seam where it joined the body of the sling. Both nurse aides assisting with the transfer reported that they had not noticed any issues with the sling prior to use and confirmed that the correct size sling was being used. As a result of the strap failure, the resident was lowered to the floor, hitting her head and left shoulder on the bed rail during the process. The resident was subsequently sent to the hospital for evaluation, where she was found to have sustained a left humerus fracture. Hospital records indicated that the resident was on anticoagulant medication and was already receiving multiple medications for chronic pain. Imaging confirmed the fracture, and the resident's arm was immobilized with a sling. She was discharged back to the facility in stable condition after assessment and treatment. Interviews with staff and a representative from the lift manufacturer revealed that the cause of the sling failure could not be definitively determined without examining the sling, but possibilities included normal wear from use and laundering or a manufacturing defect. The facility's Director of Nursing and Administrator confirmed that the sling was not old and that the resident's weight did not exceed the sling's capacity. Prior to the incident, there was no indication that the sling was in disrepair, and staff had not identified any visible defects.