Failure to Assess and Document Proper Sling Use Results in Resident Injury
Penalty
Summary
The facility failed to administer its resources effectively and efficiently to ensure the highest practicable well-being of each resident, as evidenced by the improper use of a mechanical lift sling during a resident transfer. After a resident was readmitted following hospitalization for acute respiratory failure, there was no documented assessment by a registered nurse or therapist to determine the appropriate mode of transfer, including the correct sling size. The resident's care plan and care card did not include information about mechanical lift use, sling size, sling type, or instructions on loop configuration. On the day of the incident, two certified nursing assistants attempted to transfer the resident using a mechanical lift and selected an extra-large sling without verifying its appropriateness for the resident's body size. The sling was applied incorrectly, and the resident slipped through, resulting in a fall that caused a subdural hematoma and an orbital fracture. The facility's investigation revealed that several slings in circulation lacked visible size labels, which are required for proper identification and safe use. An audit conducted after the incident led to the removal of nine slings without size labels from use. The investigation did not confirm whether the sling used was a Medline sling, as recommended by the lift manufacturer, nor did it address the need for reassessment of the resident's transfer status by a registered nurse or therapist following the change in condition at readmission. Observations of the facility's sling inventory showed that many slings lacked size and weight guidelines, and non-Medline slings were present in the inventory. Interviews with staff indicated inconsistencies in determining transfer status and equipment needs. The nurse educator stated that both registered and licensed practical nurses, as well as certified nursing assistants, could make decisions regarding the use of mechanical lifts and sling selection, but the sling size should be documented in the care plan. The certified nursing assistant involved in the incident reported not verifying the sling size and not knowing where to find other slings. The DON confirmed that the resident's transfer status was not assessed upon readmission and that certified nursing assistants could select the type and size of sling based on the resident's height and weight.