Failure to Maintain Mechanical Lift Equipment Results in Resident Falls
Penalty
Summary
A deficiency occurred when a facility failed to ensure that mechanical lift equipment was maintained in a safe and working condition, resulting in an avoidable fall for a resident. The resident, who had multiple diagnoses including schizoaffective disorder, metabolic encephalopathy, obesity, and a history of falls, was totally dependent on staff for transfers and required the use of a mechanical lift with two-person assistance. During a transfer from wheelchair to bed, the mechanical lift pad's strap broke, causing the resident to fall, hitting the bed and landing on the floor. Staff then attempted to use a different lift pad with the same mechanical lift, but the hydraulics failed, resulting in a second fall where the resident sustained injuries to the forehead, nose, left hand, and knee. The resident was assessed by nursing staff after each fall and was sent to the emergency room for evaluation. The resident reported pain and injuries, but no fractures were found. Witness statements from the CNAs involved confirmed that the lift pad was inspected prior to use and that the resident was balanced during the transfer attempts. Both CNAs and the nurse described the sequence of events, including the strap breaking and the hydraulic failure, which led to the resident falling from approximately waist height on both occasions. Observations and interviews confirmed that the same mechanical lift was used for both transfer attempts, with a different pad used for the second attempt. The mechanical lift and pad involved in the incidents were later removed from use. The facility's failure to ensure the mechanical lift and its accessories were in safe working condition directly led to the resident's falls and subsequent injuries.