Resident Fall from Mechanical Lift Due to Improper Sling Attachment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe transfer using a full body mechanical lift, resulting in a resident falling from the lift to the floor. A cognitively intact resident with traumatic spinal cord dysfunction and paraplegia, who had documented fall risk precautions, was being transferred from bed to wheelchair by two CNAs using a full body mechanical lift and a medium sling, while a third CNA in training observed. During the transfer, multiple witnesses, including the resident and the CNAs, reported hearing a snap or pop sound, after which the resident’s leg, shoulder, and then the rest of his body slipped out of the sling and he fell, striking his hip, shoulder, and head. The resident reported that he believed a strap was not hooked to the lift, which he thought allowed him to slide out of the sling. CNA H, who was observing, stated it appeared that a black strap on the sling was not securely hooked and slipped off the lift. CNA I, who operated the lift, described that the lower sling strap from the left side of the resident’s body, which had been attached to the right side of the lift bar, came off, leading to the resident landing on his hip, shoulder, and then his head. After the fall, staff observed that only three of the four sling straps remained attached to the lift, with one lower strap not attached, and no tears or broken loops were found on the sling itself. Interviews revealed that CNA I and CNA J each checked different sides of the sling attachments before the transfer, and both stated they typically double-check sling straps prior to lifting. CNA I reported she had never had the mechanical lift safety checklist competencies completed for her, and CNA J was unsure if she had completed those competencies, although both had received some form of mechanical lift education. The DON stated her assumption was that the strap was not on the inside of the hook on the lift bar and confirmed that, upon entering the room after hearing a crash, she saw three straps still attached to the lift and one bottom strap not attached. The facility’s mechanical lifts policy required that nursing personnel receive annual in-services on correct lifting and transferring procedures, including the correct use of mechanical lifts, but the report documents that the specific safety checklist competencies for mechanical lift use had not been completed for at least one of the CNAs involved in the transfer.
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