Mechanical Lift Transfer Failure Resulting in Resident Fall and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a non‑ambulatory, fully dependent resident remained free from injury during a mechanical lift transfer. The resident had multiple significant diagnoses, including multiple sclerosis, morbid obesity, chronic kidney disease, fractures of both femurs, arthritis, and low back pain, and was care planned to be transferred daily from bed to an electric wheelchair using a mechanical lift with assistance from two staff. A quarterly MDS documented that the resident had intact cognition but was dependent on staff for transfers. On the date of the incident, during a transfer from bed to wheelchair using a mechanical lift, the lift tipped and the resident fell to the floor. According to written statements from two CNAs, they were transferring or repositioning the resident with a mechanical lift when the lift tipped, causing the resident to fall and the resident’s left arm to graze the wheelchair armrest and wheel. When the supervising RN arrived, she found the resident lying supine on the floor with the head near the foot/side of the bed and feet toward the doorway, with the wheelchair nearby. The resident complained of left arm pain, appeared very anxious, and was short of breath. The resident was transported to the emergency room, where imaging was negative, and a contusion on the left side of the back was documented. Interviews and record review showed that the facility could not determine whether the correct sling size was used or whether the legs of the mechanical lift were opened to the widest position for stability at the time of the incident, despite facility policies and education materials requiring proper sling selection and full opening of the lift base during transfers. The DNS and RN supervisor both stated that CNAs are responsible for selecting the appropriate sling based on resident weight and ensuring the lift legs are opened, but neither could confirm these steps were followed during the event. The Director of Maintenance had no maintenance or repair records for the lift from the time of the incident, and there was no documentation clarifying whether equipment malfunction or staff technique contributed to the lift tipping. The facility’s policies required at least two trained staff for mechanical lift transfers and annual competency validation, but the incident occurred during such a transfer and resulted in the resident’s fall and injury.
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