Failure to Safely Attach Mechanical Lift Sling Results in Resident Fall and Fractures
Penalty
Summary
Facility staff failed to provide a safe transfer for a resident who was totally dependent on staff for bed mobility and transfers due to left-side hemiplegia following a stroke. During a transfer from bed to wheelchair using a mechanical lift with a U-shaped sling, the staff did not attach the sling according to both facility policy and the manufacturer's instructions. Specifically, the CNA responsible for setting up the sling did not cross the bottom straps between the resident's legs, which is required for safe positioning and to prevent sliding. As a result, the resident slid out of the sling during the transfer and fell to the floor. The incident involved three CNAs assisting with the transfer. One CNA had already attached the sling straps before the others arrived, and none of the assisting staff checked the strap configuration before proceeding. The resident, who was cognitively intact, reported feeling that something was wrong during the lift and subsequently slid out of the bottom of the sling. The fall resulted in acute fractures to the resident's left shoulder (proximal humerus) and left wrist (distal radius), requiring emergency medical attention, immobilization, pain management, and orthopedic follow-up. Prior to the incident, the resident had not experienced problems with lift transfers and had low pain levels. Interviews and documentation confirmed that the facility's expectation and the manufacturer's instructions were for the bottom straps of the U-shaped sling to be crossed between the legs for all such transfers. The CNA who set up the sling initially believed she had attached the straps correctly but later realized during a re-enactment that she had not crossed them. Other staff involved in the transfer did not verify the strap configuration before operating the lift. The failure to follow established procedures directly led to the resident's fall and subsequent injuries.