Injury from Improper Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a resident was mechanically transferred safely, resulting in a fall from a mechanical lift and subsequent injuries. The resident involved had diagnoses including metabolic encephalopathy, history of stroke, muscle weakness, and respiratory failure, was severely cognitively impaired per a recent MDS, and was dependent on staff for transfers and non-ambulatory. The resident’s care plan required maximum assistance of two staff with a mechanical lift for transfers. During an evening transfer from a wheelchair to a bed using a mechanical lift, two CNAs assisted the resident. According to nursing documentation, the resident fell to the ground, striking her left shoulder on the base of the lift and the back of her head, and exhibited pain behaviors such as grimacing, moaning, and crying. Written statements from both CNAs indicated that they had attached the resident’s sling straps to the lift prior to initiating the transfer. One CNA reported that three straps were hooked on the resident and that she had attached the two bottom straps and one top strap, while the other CNA attached the remaining top strap. When the lift was operated and the resident was in the air, one CNA pulled the wheelchair away, and a strap came undone, causing the resident to fall; the other CNA attempted to catch the resident but was unsuccessful. The Administrator’s investigation concluded that one of the straps likely had not fully engaged on the lift, which was the only explanation offered for why a strap would come loose. The facility’s mechanical lift policy required staff to ensure sling straps were securely attached, properly balanced, double-checked for security before lifting, and that all hooks, clips, fasteners, and strap stability be examined, indicating these procedural steps were not effectively followed during the transfer that led to the fall and injuries.
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