Improper Mechanical Lift Sling Positioning Leads to Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a mechanical lift in accordance with its own policy and the resident’s care plan. The facility’s Safe Lifting and Movement of Residents policy required that only staff with documented training use mechanical lifts and that residents be properly positioned in slings, with enough appropriate slings available. Resident #2’s quarterly assessment documented severe cognitive impairment with a BIMS score of 5 and dependence on others for most ADLs, including positioning and transfers. The resident’s care plan required the assistance of two or more staff members and the use of a mechanical lift for transfers. On 12/06/25, during a mechanical lift transfer from bed to chair, Resident #2 slipped from the sling and fell. A nurse’s progress note documented that the resident routinely received blood thinners, complained of head pain after the fall, and was transferred to the hospital. The progress note and state reportable incident indicated that two CNAs were present, witnessed the fall, and reported that the resident hit their head on the floor. The incident report stated that the CNAs were attempting to ambulate/transfer the resident in the lift and failed to secure the resident’s back far enough on the sling per facility policies and procedures, resulting in the resident falling from the top right of the sling and hitting their head on the ground. Further description from the ADON indicated that, upon reenactment of the transfer, it was immediately apparent that the CNAs had not properly positioned the sling, leaving the resident without trunk support. Because Resident #2 could not hold themselves up while in the sling, the improper sling positioning led to the resident falling from the sling. A subsequent nurse’s progress note documented that the resident sustained a small subdural hematoma requiring hospitalization. At the time of later observation on 01/07/26, the resident was noted sitting in a recliner, dressed, with the call light in reach, but the deficiency centers on the earlier transfer event in which staff failed to properly secure and position the resident in the mechanical lift sling as required by policy and the care plan.
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