Failure to Inspect and Maintain Mechanical Lift Slings Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers and had unimpaired cognition, fell from a mechanical lift during a transfer. The incident happened when the resident was being moved from their bed to a chair using a mechanical lift and sling. During the transfer, the resident slid out of the sling and ended up on the floor with their head on the ground and feet still in the sling. Inspection of the sling used revealed a cut or tear approximately three-quarters of an inch in length on one of the blue loops, which was about half the width of the loop. The remainder of the sling showed no other signs of damage or wear. The resident was subsequently transferred to a hospital, where a CT scan revealed a small subarachnoid hemorrhage, and the resident spent several days in the ICU before returning to the facility. The facility failed to ensure that mechanical lift slings were inspected as recommended by the manufacturer. The operator's manual specified that slings should be inspected monthly by nursing or rehabilitation staff, with permanent records of these inspections maintained. However, interviews revealed that while some staff claimed to have performed inspections, there was no documentation of sling inspections prior to June, and maintenance staff did not inspect the slings, believing it was not required for rented equipment. Additionally, monthly checks on the mechanical lifts were not performed in April or May, and the responsibility for inspecting slings was not clearly assigned or documented. Staff involved in the transfer reported that they did not notice the broken loop prior to use, and the resident was wearing slick pajamas at the time, which may have contributed to the fall. The sling was removed from service after the incident. The facility's policy required that all necessary equipment be in working order, but the lack of documented inspections and failure to identify the damaged sling before use directly contributed to the resident's fall and subsequent injury.