Failure to Secure Sling During Mechanical Lift Transfer Results in Resident Fall
Penalty
Summary
Facility staff failed to ensure a safe transfer of a resident with significant cognitive and physical impairments by not properly securing the sling to the mechanical lift during a transfer from bed to shower chair. The resident, who had a history of stroke, Alzheimer's disease, hemiparesis, and was assessed as requiring extensive assistance with all activities of daily living, was being transferred by two CNAs using a mechanical lift and mesh sling. According to interviews and documentation, one of the lower sling loops became detached from the lift during the maneuver, causing the resident to fall from the lift to the floor, resulting in pain to the resident's shoulders and left hip. The facility's policy on safe lifting and movement of residents required staff to use appropriate techniques and devices, ensure slings were properly attached, and verify secure connections before moving residents. The user manual for the mechanical lift also specified that all sling attachments must be checked before lifting and moving a patient. Despite these requirements, staff did not confirm that all sling loops were securely attached before proceeding with the transfer. Both CNAs involved in the transfer stated that they each attached loops on one side of the sling, but during the transfer, a loop on the left lower side came off, leading to the resident's fall. Following the incident, the resident was assessed by nursing staff and reported significant pain. The primary care physician was notified and initially ordered the resident to be sent to the hospital for evaluation, but administration directed that mobile x-rays be performed at the facility instead. The resident was subsequently treated for pain. Interviews with staff, including the DON and administrator, confirmed the expectation that staff ensure slings are securely attached before transfers, but this was not done in this case, directly leading to the resident's fall and injury.