Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nursing assistant failed to provide a safe transfer for a resident who required the use of a stand lift. The resident, who had diagnoses including multiple sclerosis and osteoporosis, was cognitively intact and required substantial assistance with transfers. The care plan specified the use of a medium-sized sling with the stand lift and assistance from one staff member. However, the nursing assistant used a large sling instead of the prescribed medium size, did not secure the waist or calf straps, and failed to ensure all loops were properly attached to the lift. During the transfer, after assisting the resident with toileting and perineal care, the nursing assistant attempted to move the resident out of the bathroom using the stand lift. At this point, one of the sling loops detached from the lift, causing the resident to fall and strike her head on the floor. The resident sustained a laceration to the back of her head, resulting in active bleeding, and was subsequently diagnosed with a mild concussion and required stitches. Interviews confirmed that the nursing assistant did not follow the care plan or facility policy regarding the use of mechanical lifts, specifically by using the incorrect sling size and not securing the required safety straps. The incident was attributed to improper use of the lift and harness, as verified by staff and a representative from the lift manufacturer. The resident's transfer status was later changed following reassessment, but the deficiency was directly related to the failure to follow established procedures for safe transfers.