F0689

J

Improper Mechanical Lift Sling Selection and Unsafe Transfer Practices

Davenport, Iowa Survey Completed on 03-25-2026

Penalty

Fine: $10,225

Summary

The deficiency involves the facility’s failure to ensure safe use of mechanical lifts and appropriate slings for residents dependent on total body lifts, including a bariatric resident. For Resident #8, who had morbid obesity, acute and chronic respiratory failure with hypoxia, anxiety, depression, and a history of potentially traumatic events, the MDS documented total dependence for transfers and the need for a mechanical total body lift with two helpers. A Mechanical Lift & Sling Size Risk Evaluation identified that this resident’s weight of approximately 535 pounds required an XXL sling on a bariatric lift. Despite this, staff reported that the sling supply was disorganized, that they relied on ribbon colors to guess sling sizes, and that some slings had worn or unreadable tags, making it impossible to verify size and weight limits. Staff also reported that the facility did not have an appropriate sling for the resident’s weight and that the only other available sling was a medium size that would not work.

On the evening of 2/26, Resident #8 complained of chest pain/indigestion while lying in bed and requested to be assisted into a recliner. The LPN on duty directed three CNAs to transfer the resident using the mechanical lift. CNAs described that the only sling available for this transfer was a blue and grey hospital slide sheet with multiple loop handles, which they had never used before at the facility and which was not like the regular netted or cloth mechanical lift slings. They placed this slide sheet under the resident, attached its loops to the bariatric lift, and began elevating the resident away from the bed. As the lift was engaged and the resident was moved, the handles on the slide sheet began to tear away from the material. Staff heard ripping sounds, and the resident stated she heard the rip and expressed fear of falling, repeatedly asking how she would get back to bed. CNAs held onto the sling and maneuvered a recliner under the resident, lowering her into a chair that was described as not big enough, with the resident “squished in.” The slide sheet tore further, with loops pulling away from the sheet, and staff were unable to safely transfer the resident back to bed.

The facility then relied on the local fire department to attempt to resolve the situation. Fire department personnel found the resident stuck in the recliner on a torn slide sheet and were told by facility staff that the sheet had begun to rip while the resident was elevated during the transfer. The Lieutenant and Fire Chief identified the device under the resident as a hospital slide/transfer sheet, not a mechanical lift sling, and stated that if the handles had completely ripped, the resident would have been seriously hurt. Fire personnel attempted to use the slide sheet again with the lift to raise the resident just enough to place another sling underneath, but the sheet began ripping again, one handle after another, and the resident had to be lowered back into the recliner. Ultimately, additional fire crew members dismantled the bed, positioned it at the foot of the recliner, and manually slid the resident into bed using the torn sheet. Facility documentation and interviews also showed that staff had called the fire department multiple times for this resident’s transfers, that staff reported insufficient equipment and staffing to safely transfer her, and that the nurse on duty had been told at shift change simply to call the fire department when the resident needed to return to bed.

For Resident #39, who had multiple sclerosis, paraplegia, renal insufficiency, and bilateral leg impairment, the MDS and a Mechanical Lift & Sling Size Risk Evaluation documented dependence on staff for transfers and the need for a total body lift with a large-size sling at a weight of 248 pounds. However, observation showed this resident sitting in an electric wheelchair on a mechanical lift sling with a purple ribbon, identified on its worn tag as a medium size. The remainder of the tag was too worn to identify the maximum weight limit. Manufacturer safety instructions for the bariatric lift specified that staff should not lift a patient unless trained and competent and must always ensure the sling is suitable for the particular patient and of the correct size and capacity. Interviews with CNAs and the Administrator revealed that staff training on sling selection was lacking, that staff were not provided formal training on Hoyer and sling use, that sling sizes were often inferred from ribbon colors, and that some slings lacked readable labels, contributing to the use of incorrect or unsafe devices for mechanical lift transfers.