Mechanical Lift Sling Deterioration Leads to Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to properly maintain and monitor mechanical lift slings, resulting in a sling strap breaking during a transfer and causing a resident to fall. Facility policy for hydraulic lifts required that all nursing staff be trained in proper use of mechanical lifts and that staff ensure sling straps are securely placed on the hooks of the carry bar prior to lifting. The manufacturer’s full body sling instructions warned that slings must be carefully inspected before each use for wear and damage, and that torn, cut, frayed, or otherwise deteriorated slings must be discarded. Additional facility guidelines for identifying deteriorated slings stated that bleach, high-temperature washing or drying, and harsh mechanical action can accelerate deterioration of sling materials, especially loop straps, and that such slings may appear intact while having compromised tensile strength. The resident involved had multiple sclerosis, muscle weakness, and an existing nondisplaced intertrochanteric fracture of the right femur at admission, and was care planned to require a mechanical lift with two staff assisting for transfers. During a transfer using a mechanical lift, two CNAs placed the sling under the resident, attached all four straps to the lift, and began lifting the resident from bed toward a wheelchair. Both CNAs reported that the sling and straps appeared intact prior to the lift. While the resident was suspended in the air and being guided toward the wheelchair, the bottom right sling strap broke. One CNA reported seeing the resident fall to the ground, and the other described the resident falling out of the sling, hitting the side of the bed, and landing on her right side. When the RN arrived, the resident was lying horizontally on her right side across the lift legs with her neck turned to the side near the nightstand. The emergency department record documented that the resident was transferred by ambulance for right hip and right arm pain after the mechanical lift sling broke during a transfer, causing her to fall onto the bed. Imaging showed an acute intertrochanteric right femur fracture and a normal humerus X-ray, and the resident was admitted to the medical-surgical floor for further treatment. Following the incident, facility staff, including CNAs and the DON, stated that management determined the sling straps were dry-rotted. Interviews with environmental and laundry staff revealed that, prior to the fall, mechanical lift slings had been bleached, washed together with sheets, and dried in a dryer with a single high-heat setting, contrary to the manufacturer’s instructions that prohibited bleach and high-temperature drying and recommended gentle laundering conditions. Staff also reported uncertainty about wash and dry temperatures and described a process in which slings were laundered and then visually checked for damage or fraying before being returned for use.
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