Improper Mechanical Lift Transfer Leading to Resident Fall and Rib Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical lift transfer by not confirming that all four sling straps were properly attached before moving a resident. The resident involved was an elderly female with hemiplegia and hemiparesis following cerebral infarction affecting the left side, osteoarthritis, and fibromyalgia, who required a mechanical lift with assistance of two staff for transfers and used a medium-sized sling. On the day of the incident, two NAs used the mechanical lift and the appropriately sized sling to transfer the resident from her wheelchair to her bed. One NA attached the right upper and lower loops of the sling while positioned on the resident’s right side, and the other NA attached the lower loops and was responsible for operating the lift. After the sling was attached, the NAs raised the resident into the air and moved the lift backward, pausing between the wheelchair and the bed to obtain the resident’s weight using the lift’s weighing feature. During this process, the top left strap of the sling came loose from the lift, causing the resident to fall from the lift onto her left shoulder. The resident sustained acute displaced fractures of the 2nd and 3rd left ribs and required transfer to the hospital for further evaluation and care. The incident was documented in a progress note and an incident report, and an IDT meeting was held regarding the fall. Interviews conducted during the survey revealed that facility policy and staff expectations required that all four sling loops be checked for secure attachment before moving a resident, including lifting the resident slightly off the surface to verify tension and stability of the loops. The DON and nurse manager stated that staff are expected to perform a safety check by slightly lifting the resident and visually confirming that all sling loops are tight and completely attached before proceeding with the transfer. The DON’s investigation concluded that the upper left loop of the sling was either not attached or not properly attached by one of the NAs, and that both NAs failed to complete the required pause and safety check prior to moving the resident away from the original surface. This failure to follow established procedures for mechanical lift use led directly to the resident’s fall and injuries.
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