Failure to Assess and Document Proper Sling/Harness Size for Mechanical Lift Transfers
Penalty
Summary
The facility failed to comprehensively assess and document the appropriate sling or harness sizes for residents requiring mechanical lifts for transfers, as required by manufacturer instructions. For two residents who utilized sit-to-stand and full-body mechanical lifts, there was no evidence of a formal assessment that included necessary measurements such as height, weight, distance from tailbone to base of neck, or torso circumference. Instead, staff relied primarily on the resident's weight and a laminated chart in the tub room to estimate sling or harness size, without documenting the specific size in the care plan or Kardex. Interviews with various staff members, including RNs, LPNs, nurse managers, and nursing assistants, revealed a lack of clarity and consistency regarding responsibility for assessing sling/harness size. Staff reported that there was no formal assessment process, and that the size was not routinely updated or included in care plans. Some staff indicated that therapy might be responsible for the assessment, while others believed it was the responsibility of nursing. The process described by staff involved using judgment and trial-and-error to determine if a sling or harness fit properly, rather than following a standardized assessment protocol. Manufacturer instructions for the mechanical lifts and slings used in the facility specify that a full patient assessment must be conducted to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy or procedure for mechanical lift equipment, and documentation for the two residents reviewed did not include a Mechanical Lift Sling Assessment. The lack of a comprehensive and documented assessment process for determining sling/harness size led to the deficiency identified by surveyors.