F0689

G

Improper Mechanical Lift Sling Attachment Leads to Resident Fall and Head Injury

Crystal Lake, Illinois Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The facility failed to ensure a resident was transferred with a mechanical lift in a safe manner, resulting in the resident falling from the lift sling and sustaining a subdural hematoma. The resident was an elderly female who had been admitted to the facility and was later readmitted with a new diagnosis of traumatic subdural hematoma. According to the State Agency Serious Injury Report, the resident was hospitalized after falling from a mechanical lift sling due to improper sling attachment to the lift hooks. A hospital discharge report documented that the resident was admitted with a subdural hematoma and a scalp hematoma, with a CT scan showing a 3-millimeter subdural hematoma.

Interviews with the Administrator and the CNAs involved in the transfer revealed that the improper use of the sling loops led to the incident. The Administrator stated that, after interviewing the CNAs, they were able to determine and recreate how the sling loop came off the lift hook: the loop strap had been wrapped around the end of the transfer bracket, creating tension that caused the loop to pop off the hook. One CNA reported that during the transfer to a wheelchair, the other CNA hooked their side of the sling and then wrapped the rest of the strap around the end of the lift bar, after which the sling came off and the resident fell. The other CNA similarly stated that they hooked the loop of the sling on the lift bar and wrapped the rest around the outer hook of the bar, and when the resident was lifted and moved toward the wheelchair, the sling came undone and the resident fell to the floor. At the time of the injury, the facility’s Safe Resident Handling/Transfers Policy required staff to maintain compliance with safe handling and transfer practices.