Failure to Ensure Safe Mechanical Lift Use and Sling Integrity
Penalty
Summary
Surveyors identified that staff failed to maintain a safe environment during mechanical lift use and sling management for two residents. For one male resident with intervertebral disc degeneration and an ADL self-care performance deficit requiring staff assistance for transfers, surveyors observed a lift sling on his overbed table with loops that were faded in color. When questioned, the CNA initially denied the fading but then acknowledged the loops were faded compared to when the sling was new and obtained another sling for the transfer. During the same observation, the CNA did not lock the brakes on the mechanical lift before raising the resident from the bed or before lowering him into his wheelchair, despite facility policy requiring the base to be stable and locked and the CNA’s own acknowledgment in interview that failure to lock brakes could cause the lift to tip and residents to get hurt. For a female resident with cerebral palsy, severe cognitive impairment (BIMS score of 00), and dependence on staff for transfers using a mechanical lift with two staff members, surveyors observed her seated in a wheelchair in a common area with a mechanical lift sling underneath her. The sling’s loops were noted to be fraying. The Laundry Director stated that slings were laundered without bleach and air dried and that she would show any sling with discoloration, fading, rips, or tears to the DON so it could be removed if needed, acknowledging that residents could be hurt if a sling broke during transfer. The Resource RN stated she expected staff to follow policy and procedures for mechanical lift use, including locking brakes and inspecting slings for damage or wear, and stated that failure to lock brakes or use of an unsafe sling could result in resident injury. Facility policy required ensuring mechanical lift equipment was in good working condition, performing safety checks per manufacturer recommendations, inspecting slings for damage or wear before use, and positioning the lift with a stable, locked base.
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