F0689

D

Failure to Assess and Communicate Proper Sling/Harness Sizing and Leg Strap Use for Mechanical Lifts

Winona, Minnesota Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to comprehensively assess and document appropriate sling and harness sizes, and to consistently use required safety components (leg strap) for mechanical lift transfers, as required by manufacturer instructions. Two residents who depended on mechanical lifts for transfers were affected. One resident had intact cognition with a history of ischemic stroke, left hemiparesis, hemiplegia, unsteadiness on feet, impaired balance, limited mobility, incontinence, impaired vision, and a history of falls. This resident required substantial to maximal assistance for transfers and used a motorized wheelchair. The care plan and group assignment sheet directed staff to use a gait belt and walker or an EZ Stand sit‑to‑stand lift, and later referenced use of a pivot/EZ Stand for transfers, but did not identify the required harness size or whether the leg strap was to be used.

For this resident, the clinical record lacked any comprehensive assessment for harness size that incorporated the resident’s weight and torso circumference where the harness is applied, as required by the manufacturer. The record also did not address whether the leg strap should be used. A fall report documented that the resident was elevated in an EZ Stand lift with both feet under him and the leg strap not in use; his feet slipped off the platform, leaving him hanging in the lift until a nurse supported his weight and repositioned his feet so he could be lowered to the floor. The resident reported that his foot did not get all the way on the platform, both feet slipped off because his shoe slipped, and he was hanging on until help arrived. The record did not include a comprehensive assessment identifying the size of sling required for use of a full body mechanical lift. In subsequent interviews, the resident and the RN who responded to the incident both described that the resident’s left foot slipped out of his shoe, both legs were trapped underneath him, he was not strong enough to hold himself up, and the leg strap was not believed to have been used.

The second resident had intact cognition with diagnoses of multiple sclerosis, generalized weakness, repeated falls, dependence on a wheelchair, and impaired range of motion in both lower extremities. This resident was dependent on staff for transfers, used a motorized wheelchair, and required assistance of two staff with a Hoyer full body mechanical lift. The care plan did not identify the size of sling required for safe transfers, and the record lacked a comprehensive sling size assessment including height, weight, girth, and the distance from tailbone to base of neck, as required by manufacturer guidelines. The resident reported that two staff transferred her with a Hoyer lift and that she did not know what size sling was used, assuming staff would know.

Multiple nursing assistants reported that sling and harness sizes were not identified on care plans, Kardexes, or assignment sheets for residents requiring mechanical lifts. They stated that each resident had a sling or harness in the room, but they were unable or unsure how to determine the correct size, and if a sling became soiled they would obtain another from the supply or linen room without a reliable method to select the appropriate size, especially when tags were worn or unreadable. One nursing assistant reported inconsistent use of the EZ Stand leg strap among staff and expressed concern that the leg strap should be used to prevent legs from slipping out. Another assistant who performed EZ Stand transfers stated she had not received training on use of the leg strap and was unfamiliar with it. The RN and DON confirmed that the facility did not complete formal, documented sling or harness size assessments, relied on a weight‑based reference chart in the linen room, did not document sling/harness size in the medical record, care plan, or assignment sheets, and had no system to monitor weight changes that might require size adjustments. The occupational therapist and the EZ Way lift representative both stated that a full patient assessment is required to determine appropriate accessory size and type, that the leg strap is essential or policy for safe EZ Stand use, and that sizing must be based on manufacturer charts using resident‑specific measurements such as weight, torso circumference, and tailbone‑to‑neck distance.