Failure to Maintain Ceiling Lift in Safe Working Condition
Penalty
Summary
The facility failed to ensure that a MaxiSky Lift, a ceiling-mounted lift used for transferring and repositioning residents, was maintained in safe working condition prior to use. During incontinence care for a resident with multiple complex medical conditions, including hemiplegia, heart failure, and diabetes, it was observed that the safety latch on the MaxiSky Lift was broken on one side. Both CNAs providing care were aware of the broken latch but were unsure how long it had been in that condition. The resident required substantial to maximum assistance or was dependent in all functional abilities, according to the most recent assessment. Review of the manufacturer's instructions for the MaxiSky Lift indicated that all safety features, including end stoppers and safety latches, must be intact and inspected before every use. The instructions specifically stated not to use the lift if any damage or missing parts were identified. Despite this, the lift was used to transfer the resident while the safety latch was broken, as confirmed by staff interviews and direct observation. The manufacturer's representative confirmed that the safety latch is a secondary safety feature designed to prevent patient falls during transfers.