Failure to Assess and Document Proper Sling/Harness Sizes for Mechanical Lift Transfers
Penalty
Summary
The facility failed to comprehensively assess and document the appropriate sling and harness sizes for residents requiring mechanical lifts for transfers, as per manufacturer instructions. For two residents with significant mobility impairments and histories of falls, the care plans, Kardexes, and therapy/nursing communication forms did not specify the required sling or harness sizes. Although assessments noted residents' heights and weights, they did not include all manufacturer-recommended measurements, such as the distance from tailbone to base of neck or torso circumference, which are necessary for proper sizing and safe transfers. Direct care staff interviews revealed that nursing assistants determined sling and harness sizes primarily based on residents' weights and reference charts, rather than comprehensive assessments. Staff reported relying on slings or harnesses found in residents' rooms or consulting with other aides if uncertain about sizing. There was inconsistency among staff regarding which size should be used for each resident, and the required measurements for proper fit were not routinely obtained or documented. The lack of clear documentation in the care plans and Kardexes meant that staff did not have immediate access to the correct sling or harness size information during transfers. The assistant director of nursing confirmed that comprehensive sling and harness assessments had not been completed for the residents in question, which resulted in the absence of this information in their care plans. Manufacturer instructions for the mechanical lifts and harnesses emphasize the need for a full patient assessment to determine the appropriate accessory size and type prior to each use. The facility was unable to provide a policy and procedure for mechanical lift equipment upon request.