Failure to Ensure Safe Condition of Mechanical Lift Sling Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a mechanical sit-to-stand lift sling was in good working order before use, resulting in a fall during transfer. A resident with surgically repaired cervical stenosis stabilized with rods and screws, spinal cord dysfunction, weakness of extremities, and non-ambulatory status required staff assistance and use of an EZ stand mechanical lift with two staff for transfers. The resident’s care plan and interventions identified the need for staff to inspect slings for visible signs of wear or decreased integrity and for therapy to confirm safety with sit-to-stand transfers and weight-bearing ability. On the day of the incident, two CNAs were transferring the resident from bed to wheelchair using the mechanical sit-to-stand lift. One CNA reported that she checked the sling and saw no issues before placing it around the resident’s back and under his arms, attaching the loops to the lift, and elevating him to a standing position. While the resident was standing, slightly bent forward, the sling strap snapped off where it attached to the body of the sling, causing the resident to fall to his knees, partially on the lift and partially on the floor, and graze the back of his head/neck on the bed frame. Initially, there were no visible injuries and no immediate complaints of pain, but later the resident reported dull, aching right knee pain and subsequently requested ER evaluation. Record review showed that the resident was diagnosed in the ER with a neck strain and a sprain to the right knee following the fall. Observation of the involved sling revealed that the strap had torn off at the attachment point to the sling body, the rings on the strap were intact but stiff, and the sling label was torn and faded with no visible manufacturer directions, with the resident’s name written over the torn label. Manufacturer guidelines provided by the DON stated that sling condition should be checked prior to use, that slings with illegible wash tags should not be used, and that reusable slings should be replaced every six months. Additional guidance from the manufacturer’s website indicated that completely faded or missing tags and strap brittleness or stiffness are indicators of deterioration and loss of tensile strength, even when the sling appears otherwise intact, and such slings should not be used for lifting a resident.
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