F0689

D

Unsafe Use of Damaged Mechanical Lift During Dependent Resident Transfer

Dwight, Illinois Survey Completed on 01-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe use and maintenance of a mechanical lift during transfers for a resident who was severely cognitively impaired and dependent on staff for all transfers. The resident’s MDS/Quarterly assessment documented severe cognitive impairment, bilateral upper and lower extremity impairments, and total dependence on staff for transfers, with the care plan specifying use of a full-body mechanical lift with two-person assistance. The facility’s written policy on Transfers–Manual Gait Belt and Mechanical Lifts required routine maintenance checks by nursing and maintenance staff to ensure equipment remained in good working order, and the manufacturer’s user manual required completion of a daily checklist before use, including examination of sling hooks and related components for excessive wear and non-use if there was any doubt about safety.

Despite these requirements, staff used a mechanical lift with a known broken component on the spreader bar where the sling straps attach. A CNA reported that the full circular plastic piece at one end of the spreader bar, which kept the sling straps from coming out, was broken in half, and confirmed that the side of the sling that came off during the incident was the side with the broken plastic circle piece. The Maintenance Director also confirmed that the lift used on the resident had a broken round plastic piece on the spreader bar, with half of it missing. The Administrator stated that staff should have removed the lift from service and reported the broken piece immediately, indicating that the lift was used for the resident’s transfer while in a damaged and unsafe condition, contrary to facility policy and manufacturer instructions.