Failure to Use Correct Mechanical Lift Sling Size During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to use the correct size mechanical lift sling during the transfer of a resident who was dependent on staff for all transfers due to limited physical mobility and a history of chronic osteomyelitis, anxiety, and abnormal gait. The resident's care plan required the use of a mechanical lift with two staff for all transfers, but documentation did not specify the appropriate sling size. During a transfer for a shower, nurse aides experienced difficulty positioning the resident, causing pain to the resident's right leg, which had previously undergone surgery. The resident expressed discomfort and attempted to refuse the transfer, but the transfer proceeded with continued difficulty. Interviews revealed that one nurse aide recognized the sling was too small but was overruled by another aide, who insisted on using the same size sling. During the transfer, the resident's leg was not properly supported, resulting in pain and the resident's leg hitting a bedside table. Upon returning from the shower, a latch on the sling slipped off the lift, causing the resident to begin to fall backward, though a staff member intervened to break the fall. The DON confirmed that the wrong sling size was used and that the sling was improperly placed, leading to inadequate support and pain for the resident.