Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer of a resident using an EZ Way smart lift, resulting in the resident falling from the sling and sustaining a scalp contusion and a closed wedge compression fracture of the T4 vertebra. The resident, who had diagnoses of intellectual disabilities and osteoporosis and was fully dependent on staff for transfers, required two staff members and the use of a mechanical lift for all transfers according to her care plan. On the day of the incident, two nursing assistants, both under the age of eighteen, attempted to transfer the resident without following facility policy or the manufacturer's instructions. During the transfer, one nursing assistant attached only the upper right sling strap and was distracted by another resident's needs, leaving the area. The other assistant, also underage, began operating the lift without verifying that all straps were secured and without the required adult supervision. As a result, the resident leaned forward and fell out of the lift onto the floor. Interviews confirmed that both staff members were aware that at least one adult should have been present and that all straps needed to be checked before operating the lift, but these procedures were not followed. The EZ Way representative confirmed that the lift and sling were functioning properly and that the incident was due to improper use. The facility's policies and the manufacturer's instructions both required two staff to be present, with one being at least eighteen years old, and for all four sling straps to be checked before lifting. The medical director confirmed that the injuries were acute and directly resulted from the fall during the transfer.
Removal Plan
- Reviewed policies on use of mechanical lifts.
- Re-assessed R1 and all residents who utilize a mechanical lift.
- Re-educated all staff who use the mechanical lift on the policy and procedure and did competency testing.
- Completed audits observing staff transferring residents with mechanical lifts; results would be brought to Quality Assurance and Performance Improvement (QAPI) committee.
- Developed an ongoing plan for safe transfer education in QAPI meeting.