Failure to Ensure Safe Transfer Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when staff failed to properly attach a lift sling to a ceiling lift bar during a transfer of a resident with severe cognitive and physical impairments. The resident, who had diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, aphasia, seizure disorder, and muscle weakness, was fully dependent on staff for all activities of daily living and transfers. During a transfer from bed to wheelchair, two nursing assistants attached the sling straps to the ceiling lift, but one of the straps was not fully secured. As the resident was lifted, a strap detached, causing the resident to fall from the lift, landing on a floor mat and sustaining a large contusion and hematoma to the back of the head, as well as a skin tear to the forearm. The resident required evaluation in the emergency department and experienced pain requiring medication. The incident was substantiated through staff interviews, reenactments, and document review. It was determined that the left leg sling strap was not properly hooked to the lift bar, and staff did not perform a double-check to ensure all straps were secure before initiating the lift. The facility's procedures and competency checklists did not explicitly require a double-check of sling strap security prior to lifting, and staff involved in the incident did not verify the connections after the resident was slightly lifted off the bed. Additionally, after the fall, the same ceiling lift was used to transfer the resident and another individual before the equipment was inspected, contrary to facility policy requiring removal of equipment from service after an adverse event. Observations and interviews revealed that the sling and lift were appropriate for the resident's care plan at the time, but the failure to ensure proper attachment and verification of the sling straps directly led to the resident's fall and injury. The staff involved did not intentionally cause harm, but the lack of adherence to safety protocols and insufficient verification of equipment setup resulted in actual harm to the resident.