Failure to Use Correct Mechanical Lift Sling Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when a resident with paraplegia, chronic pain, weakness, and anxiety disorder, who required staff assistance for transfers, was not safely transferred using the appropriate equipment. The resident's care plan specified the use of a small full body mechanical lift sling for transfers due to their high risk for falls. On the day of the incident, two nurse aides attempted to transfer the resident using a standard sling instead of the required full body sling because the correct sling could not be located. One aide was aware of the care plan instructions but did not seek assistance to find the correct sling and proceeded with the transfer using the available standard sling. During the transfer, the resident began to slide out of the standard sling, and the staff attempted to lower the resident to the floor. The resident complained of moderate pain to the right backside of the head and was found to have a small bump and a skin tear. Shortly after the incident, the resident experienced a change in level of consciousness and was transferred to the emergency department. Initial CT scans were negative, but a follow-up scan revealed a small subdural hematoma. Interviews with the involved nurse aides revealed that both were aware, or should have been aware, of the requirement to use the full body sling as indicated on the resident's care card. One aide admitted to not using the correct sling and not asking for help, while the other assumed the correct sling was in use based on visual cues. The facility's mechanical lift transfer policy required staff to ensure the proper sling size was used and that slings were securely attached before and during transfers, but these procedures were not followed, resulting in the resident's fall and injury.