Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with dementia and osteoporosis, who was severely cognitively impaired and dependent for transfers, was not safely transferred using a mechanical lift as ordered by the physician and outlined in the care plan. During a transfer from bed to wheelchair by two nurse aides, the upper left strap of the mechanical lift sling detached from the hook, causing the resident to partially slip from the sling and strike their head and shoulder on the ground. The resident sustained a hematoma to the back right side of the head and was subsequently transferred to the hospital, where an acute L2 vertebral fracture was identified. Interviews with the nurse aides involved revealed that one aide attached the lower straps while the other attached the upper straps, but neither verified that all straps were fully secured before lifting the resident. Both aides acknowledged that they did not check the security of the straps prior to moving the resident off the bed. Facility policy required special care and attention when using a mechanical lift, including ensuring all straps are securely attached before lifting. The failure to confirm the proper attachment of the sling straps directly led to the resident's fall and injury.