Failure to Remove and Report Broken Mechanical Lift Used for Resident Transfers
Penalty
Summary
Facility staff failed to follow established Resident Safety and Maintenance Service policies and procedures regarding the use and maintenance of mechanical lifts. Staff were aware that a mechanical lift, used to transfer non-ambulatory residents, was broken but did not report the issue or remove the equipment from service. Instead, the broken lift continued to be used to transfer four residents who were entirely dependent on staff for mobility and could not bear weight. Observations confirmed that the lift's legs would open and close on their own, and the handle used to operate the legs would detach, yet staff continued to use the device for multiple transfers throughout the day. Interviews with CNAs and the Maintenance Supervisor revealed that the mechanical lift had a history of malfunctioning, with staff reporting the issue verbally but not documenting it in the maintenance log. The Maintenance Supervisor acknowledged knowledge of the recurring problem with the handle but did not ensure the lift was removed from service. Maintenance staff also failed to perform thorough inspections, as they did not check the security of the handle during routine checks, and there were lapses in monthly maintenance documentation for the mechanical lifts. The user manual for the lift specified that damaged or broken lifts should not be used, and that the handle must be locked in place for safe operation, but these instructions were not followed. Residents affected by the deficiency included individuals with quadriplegia, dementia, muscle weakness, and adult failure to thrive, all of whom were fully dependent on staff for transfers. One resident expressed concerns about the safety of the lift, describing experiences where the legs would close or the handle would detach during transfers, causing instability and fear. Despite these ongoing issues, the broken lift remained in use, and there was no evidence that the Administrator or other responsible parties were notified of the equipment's condition.