Failure to Ensure Safe Mechanical Lift Transfers Due to Improper Sling Sizing and Lack of Assessment
Penalty
Summary
A deficiency occurred when a resident with quadriplegia, a history of cervical spine fracture, and other complex medical conditions was transferred using a full-body mechanical lift and an incorrectly sized sling. During the transfer, the resident fell from the sling, striking her head on the floor and sustaining a hematoma behind her left ear. The staff involved, an LPN and a CMA/CNA, reported that all four sling straps were attached, but the sling slipped or became unhooked, resulting in the fall. The resident required hospital evaluation and imaging, which confirmed the hematoma but no acute fracture. The facility failed to ensure that sling sizes were properly assigned and used according to the manufacturer's instructions. Multiple brands and sizes of slings were in use, but staff relied on a single sizing chart (EZWay) for all brands, despite each manufacturer having different sizing criteria. For example, the Guldmann brand required three body measurements, not just weight, to determine the correct size, but these measurements were not performed. Observations and interviews revealed that staff were unaware of the differences in sizing guides and often selected slings based on availability or assumptions rather than proper assessment. Additionally, the facility lacked policies and procedures for assessing residents for mechanical lift use, determining appropriate sling size, and documenting this information in care plans. There was no clear assignment of responsibility for these assessments, and therapy staff did not evaluate residents for sling size. As a result, several residents were observed using slings of undetermined or potentially incorrect sizes, and staff could not confirm the appropriateness of the slings in use. The absence of standardized assessment and documentation contributed to the unsafe transfer and subsequent injury.