Resident Fall Due to Improper Sling Attachment During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and proper use of assistive devices during a transfer with a mechanical lift. The resident, who was on hospice services and required the assistance of two staff members for transfers using a Hoyer lift, was being transferred by two CNAs with an LPN present. During the transfer, while the resident was elevated in the sling, she shifted her weight, resulting in a loud pop as a sling loop disengaged from the lift bar. This caused the lift bar to shift to a perpendicular position, and the resident fell from the sling to the floor, sustaining a laceration to the forehead that required staple closure. A thorough investigation, including reenactments and staff interviews, determined that the resident's movement during the transfer caused the right upper sling strap to slide along the moveable strap attachment bar, which then rotated perpendicular to the main crossbar. This configuration, combined with the resident's poor bodily control, led to the upper sling strap disengaging from the bar, resulting in the fall. Upon assessment, the resident was found on the floor with the upper right loop of the lift pad unattached to the bar, and was subsequently transported to the hospital for treatment.