Failure to Ensure Competent Use of Mechanical Lifts and Slings Resulting in Resident Death
Penalty
Summary
Nursing staff at the facility did not possess the necessary competencies and skills to safely use mechanical lifts and slings for resident transfers, as evidenced by direct observations, interviews, and record reviews. Certified Nursing Assistants (CNAs) were not adequately educated on the correct use of Hoyer lifts, the identification and use of approved Hoyer slings, or how to distinguish transfer sheets from lift slings. Multiple staff members reported either never receiving hands-on training or only having received training many years prior, with some staff indicating they had not been updated on new policies or equipment. A critical incident occurred when a newly admitted resident, who had significant medical conditions including acute gastric ulcer with hemorrhage, congestive heart failure, and morbid obesity, was transferred from another facility. The resident arrived on a stretcher with a blue transfer sheet underneath her. CNAs at the receiving facility used the transfer sheet, mistaking it for a Hoyer lift sling, to transfer the resident using a mechanical lift. Despite warnings from the transport driver that the sheet was not intended for use with a lift, the CNAs proceeded. During the transfer, the straps of the transfer sheet broke, causing the resident to fall onto the legs of the Hoyer lift. The resident became unresponsive and was later pronounced deceased. Interviews with staff revealed a lack of understanding regarding the differences between transfer sheets and Hoyer slings, as well as inconsistent practices regarding the use of slings that accompanied residents from other facilities. Some CNAs admitted to routinely using transfer sheets with Hoyer lifts, while others were unclear about the proper procedures or the lifespan of slings. The facility's policy regarding the exclusive use of facility-owned and approved equipment had not been communicated to all staff at the time of the incident.