Unsafe Mechanical Lift Transfer Resulting in Resident Fall and Fractures
Penalty
Summary
The deficiency involves the facility’s failure to safely transfer a resident using a full mechanical lift, resulting in the resident falling from the sling during a bed-to-wheelchair transfer. According to the incident report, the resident, who was alert with some baseline confusion, was being transferred with two-person assist when the sling became unhooked and the resident fell out of the mechanical lift sling. Staff interviews indicated that the resident had a tendency to fidget with or grab the sling or crossbar, and the care plan (developed the day after the incident) later identified a behavior of grabbing at the sling due to anxiety during mechanical lift transfers. On the day of the incident, the resident’s family requested that he be transferred to a wheelchair for a visit. A CNA whose usual partner was on lunch asked an RN to assist with the transfer. Both staff reported that they hooked the sling to the mechanical lift and checked the loops on the hooks before raising the resident. During the transfer, the RN pulled the lift away from the bed while the CNA positioned herself between the resident’s feet and bottom to guide him toward the chair. The CNA reported that the lift became caught on a cord under the bed, causing the lift to jerk, after which the left upper loop of the sling came unhooked and the resident fell rapidly to the floor. As a result of the fall, the resident landed on his head and left shoulder while his right leg remained stuck in the sling still attached to the lift. Staff observed a bump on the left lateral side of the resident’s head, and the resident complained of pain to the left shoulder, right knee, and back. Hospital documentation later confirmed that the resident, who had a history of CKD, HTN, epilepsy, prior stroke with left-sided weakness, and severe osteopenia, sustained a displaced right distal femur fracture and multiple acute/subacute spinal compression fractures following the fall from the mechanical lift.
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