Neglect Due to Improper Mechanical Lift Sling Use Resulting in Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan for safe transfers using a mechanical lift. The resident had a quarterly MDS showing cognitive impairment, dependence on staff for daily care needs and transfers, and diagnoses including Parkinson’s disease, dementia, and orthostatic hypotension. The resident’s care plan identified a potential for falls related to a new environment, adjustment to nursing home placement, tremors, orthostatic hypotension, Parkinson’s, and impaired mobility, and specified that all transfers were to be completed with a full mechanical lift using a large sling size. On the day of the incident, two nurse aides attempted to transfer the resident out of bed for a shower using a mechanical lift. During this transfer, the resident fell backwards out of the sling and hit the floor. A nursing note documented that the nurse entered the room and found the resident lying on his right side between the legs of the mechanical lift, with his head near the center post of the lift at the doorway. The lift’s legs were in the closed position, the lift arm was in a high position, and the sling remained on the hooks of the lift while it was moved. Blood was observed along the occipital region of the resident’s head extending to the left ear and on the floor from a head laceration, and the resident complained of headache, back-of-head pain, neck pain, and back pain. The resident was sent to the hospital and was diagnosed with a scalp laceration requiring staples, a closed head injury, and a fracture of the sixth thoracic vertebra. During the facility’s investigation, a registered nurse observed that the sling used for the transfer was marked as extra-large and had long leg straps that were supposed to be placed between the legs, crisscrossed, and then attached to the lift. Instead, the straps had been attached with the two right straps together and the two left straps together, not crisscrossed. The investigation determined that the fall was caused by the use of the wrong sling size, and the DON confirmed that neglect was substantiated because the nurse aides did not follow the resident’s care plan requiring use of a large sling size for transfers with the mechanical lift.
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