Failure to Monitor and Maintain Lift Equipment Results in Resident Injury
Penalty
Summary
A resident with morbid obesity, who was dependent on staff for all transfers and required a mechanical lift with two staff members for assistance, sustained a femur fracture during a transfer. The incident occurred when staff were transferring the resident post-shower using a Hoyer lift, and the lift sling broke while the resident was suspended, causing the resident to fall to the floor. The resident reported severe pain in the right leg, which was observed to be rotated inward and warm to the touch. Surgery was subsequently performed for the femur fracture. Review of facility records and staff interviews revealed that there was no documentation of routine monitoring or inspection of lift slings for signs of wear, such as frays or holes. Although staff reported that they always used two people for transfers and checked the slings, there was no formal process or documentation in place to ensure the slings were in good repair. The lack of documented monitoring contributed to the use of a defective sling, resulting in the resident's injury.