Failure to Inspect Mechanical Lift Sling Leads to Resident Fall During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a mechanical lift and to follow its fall prevention and transfer policies for one resident. The resident had medical diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side, essential hypertension, type 2 diabetes mellitus, obesity, and peripheral vascular disease, and required a full-body mechanical lift for transfers. The resident’s cognition was intact, with a BIMS score of 15. On the day of the incident, the resident was transferred from a shower bed to a mechanical lift in the hallway outside the resident’s room, rather than in the room, after receiving a shower. According to progress notes and staff interviews, a CNA placed the resident in the mechanical lift and began the transfer toward the resident’s bed. The CNA reported that the resident had been on a sling that was already under the resident from an earlier shift and that she did not realize the sling was defective. The CNA stated she did not notice the worn-out strap before attempting the transfer. While the resident was suspended in the air on the mechanical lift near the doorway to the resident’s room, the foot straps of the mechanical lift sling broke, causing the resident to fall to the floor on her buttocks and one leg. A nurse who came to assist reported that the resident was already on the lift when she arrived, that the sling strap broke during the transfer, and that she did not know whether the CNA had assessed the sling for wear and tear before use. The resident reported that the CNA told her the room was too congested and that the transfer to the lift would be done in the hallway. The resident stated that after being lifted, the CNA said something did not feel right and sought help, at which point an LPN came to assist, and then the sling strap broke and the resident fell. The resident described falling on one leg and her buttock, experiencing swelling in her left leg and ongoing pain after the fall, and feeling frightened whenever staff transfer her. The restorative nurse stated that staff are trained to inspect mechanical lift slings for wear and tear and that the sling should have been inspected prior to placing it under the resident and before the transfer. The DON stated that a quick inspection of the mechanical lift sling could have prevented the fall and confirmed that the mechanical lift is for transfers and not for transporting residents, and that moving the resident from the hallway to the bed in this manner would be considered transporting. The facility’s policies and the lift manufacturer’s manual require inspection of slings for damage and removal of malfunctioning equipment from service, which was not done in this case, resulting in the resident’s fall from the mechanical lift.
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