Failure to Ensure Proper Sling Size Use During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that staff utilized the proper sling sizes when performing transfers via mechanical lift for four out of five residents who required such assistance. Observations, interviews, and document reviews revealed that care plans for these residents did not specify the appropriate sling size, and staff often used slings that did not correspond to the residents' weights or manufacturer recommendations. For example, one resident with a history of lumbar spine fracture, obesity, and heart disease was transferred using a sling that was not indicated in the care plan, resulting in a significant bruise on the inner thigh, which the resident attributed to the lift sling. Further review showed that other residents with conditions such as respiratory disease, dementia, Parkinson's disease, and above-knee amputation were also transferred using slings of incorrect sizes. In several cases, the slings observed in use did not match the sizes recommended by the residents' assessments or the sizing charts. Staff interviews indicated a lack of knowledge regarding how to determine the correct sling size, and care plans consistently lacked documentation of the required sling size for each resident. The facility's policy required that care be provided in accordance with the care plan and manufacturer recommendations for sling size. However, there was no evidence that the facility assessed or addressed the use of incorrect sling sizes after injuries occurred, nor was there documentation of staff training or corrective measures to prevent recurrence. The interim DON and other staff acknowledged uncertainty about sling selection and the absence of root cause analysis following resident injury.