Failure to Assess and Document Proper Sling Use Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents, resulting in actual harm. A resident with vascular dementia, dysphagia, chronic kidney disease, and severely impaired cognition was readmitted to the facility after hospitalization for acute respiratory failure. Upon readmission, there was no documented assessment by a registered nurse or therapist to determine the resident's transfer status or the appropriate sling size for mechanical lift use, despite the resident's unsteady gait and poor balance. The care plan and care card did not include instructions for mechanical lift use, sling size, sling type, or loop configuration. On the day of the incident, two certified nursing assistants attempted to transfer the resident using a mechanical lift after determining the resident was too weak for a walker transfer as indicated on the care card. They selected an extra-large full-body sling, which did not fit the resident's body size, and used it because it was the only available sling on the unit. The staff did not verify the resident's weight or ensure the sling was appropriate for the resident's size. During the transfer, the resident slipped through the sling, fell, and sustained a subdural hematoma and orbital fracture. The investigation revealed that several slings in the facility lacked visible size labels, and there were non-manufacturer slings in circulation. Interviews with staff indicated inconsistent practices regarding who determines transfer status and sling selection, with some staff believing certified nursing assistants could make these decisions independently. Training on sling selection and mechanical lift use was found to be inadequate, with at least one certified nursing assistant reporting incomplete hands-on training. Documentation of sling size and type in care plans was lacking, and there was confusion among staff about proper procedures for assessing residents and updating care plans after admission or readmission.
Removal Plan
- Revise the facility policy on resident admissions and readmissions to include a registered nurse assessment which addresses a resident's height, weight, shoulder circumference, and chest circumference.
- Retrain all certified nursing assistants and licensed nursing staff on the admissions and lift/transfer policies and attest that all remaining nursing staff will complete mandatory training prior to their next scheduled shift.
- Reassess all residents identified as needing a full mechanical lift for transfers and assign an appropriate lift sling.