Mechanical Lift Used for Dependent Resident with Missing Safety Latches
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a mechanical lift in safe working condition and to ensure the environment was free from accident hazards. One resident, admitted with lumbar spinal stenosis and documented as cognitively intact with a BIMS score of 15, was assessed as having impaired upper and lower extremities bilaterally and being dependent for all functional abilities, including toileting, bathing, dressing, hygiene, turning/repositioning, and transferring. During an observation of incontinence care and a transfer from bed to a shower bed using a mechanical lift, surveyors noted that five of the six safety latches on the lift hooks were missing. During the same observation, the two CNAs performing the transfer confirmed that five of the six safety latches were missing and were unable to state how long the latches had been absent. Review of the mechanical lift manufacturer’s user manual showed that staff were required to check all sling attachments and hardware each time the lift was used to ensure proper connection and patient safety. Additionally, review of the facility’s Maintenance Inspection policy indicated the facility would use a maintenance checklist to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Despite these requirements, the lift was in use with missing safety latches at the time of the observed transfer.
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