Failure to Ensure Safe Mechanical Lift Use and Maintenance Resulting in Resident Injuries
Penalty
Summary
The facility failed to ensure the safe use and maintenance of mechanical lifts, resulting in significant injuries to two residents. In one incident, a resident with multiple medical conditions, including schizoaffective disorder, diabetes, Parkinson's disease, and mild cognitive impairment, required extensive assistance and the use of a mechanical lift for transfers. During a transfer, staff used an incorrect, thin hospital sling that was not designed for the specific lift, leading to the sling breaking and the resident falling to the floor. The resident sustained multiple rib fractures and a scalp contusion, requiring admission to a surgical trauma intensive care unit. In a separate incident, another resident with dementia, hemiplegia, and a history of stroke, also dependent on staff and a mechanical lift for transfers, was injured when the metal swivel bar of the lift struck her forehead after a transfer. The impact caused a laceration that required four staples. The incident occurred when only one staff member remained in the room while moving the lift away from the resident, resulting in the injury. Both incidents were confirmed through medical record review, staff interviews, and observation. The facility's failure to use the appropriate sling for the mechanical lift and to maintain the lift according to the manufacturer's instructions directly contributed to the residents' injuries. The manufacturer's guidelines specified that only designated slings should be used with the lift and that protective padding should be present on the swivel bar, which was not consistently followed.