Failure to Protect Residents During Investigation of Lift Transfer Accident
Penalty
Summary
A deficiency occurred when the facility failed to provide sufficient protection to other residents during the investigation of an accident involving a resident who fell from a ceiling lift during a transfer. The resident involved had severely impaired cognition, disorganized thinking, and physical behavioral symptoms directed toward others, and was dependent on staff for all transfers. During a transfer from bed to wheelchair, the resident fell from the ceiling lift after one of the sling straps became detached, resulting in the resident landing on the floor mat and sustaining a hematoma to the back of the head and a skin tear to the forearm. The incident was witnessed by staff, and it was determined that the sling strap was not fully secured to the lift bar, which led to the fall. Following the incident, the same ceiling lift was used to transfer the resident from the floor to the wheelchair, and then to transfer another resident, before any inspection or removal of the equipment from service. Staff involved in the incident continued to work on the floor and performed additional transfers with the ceiling lift before receiving re-education or competency checks. The facility's policies required that any lift or sling involved in an adverse event be immediately removed from service pending inspection, but this was not followed. Interviews revealed that staff did not double-check the sling loops before lifting, and the competency checklist did not require a double-check of the sling loops prior to lifting the resident. The failure to immediately remove the lift and sling from service and to restrict staff involved in the incident from performing further transfers before retraining resulted in insufficient protection for other residents who required staff assistance with total body lift transfers. The deficiency was substantiated through interviews, document review, and reenactments, which confirmed that the incident occurred as described and that facility policies and procedures were not followed at the time of the event.