Improper Mechanical Lift Transfer Leads to Resident Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a whole-body mechanical lift, resulting in the resident falling from the lift to the floor. The resident was admitted with diagnoses including dependence on dialysis, end stage renal disease, morbid obesity, and chronic obstructive pulmonary disease. An MDS dated 11/15/25 documented that the resident required two staff for all transfers and that staff were to use a full-body lift for transfers. The MDS also documented a BIMS score of 15, indicating no cognitive impairment. The resident’s care plan identified impaired physical mobility related to decreased strength, limited weight-bearing tolerance, and dependence on a mechanical lift for transfers. On the day of the incident, two CNAs entered the resident’s room to transfer the resident from bed to wheelchair using a whole-body mechanical lift and a bariatric sling. According to the facility’s serious injury incident report and staff interviews, the CNAs placed the sling under the resident, attached the sling straps to the lift, and raised the resident in the air over the bed to obtain a weight. They then began to move the lift to position the resident over the wheelchair. While the lift was moving with the resident suspended, the bottom right sling strap slipped or slid off the hook on the lift. Staff interviews indicated that one CNA operated the lift while the other prepared and maneuvered the wheelchair. One CNA reported hooking the bottom straps while the other hooked the top straps. During the transfer, as the lift was being moved with the resident elevated, the bottom right strap detached from the lift, causing the resident to slide out of the sling and fall to the floor. The CNAs and the nurse on duty confirmed that the resident fell when the sling strap came off the lift. The resident was subsequently transported by EMS to a local emergency room, where records documented that the resident sustained a right hip fracture, a distal right femur fracture, and a right tibia fracture as a result of falling from the mechanical lift.
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