Failure to Use Stand Lift Brakes per Manufacturer Instructions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow the manufacturer’s instructions and facility expectations for use of a bariatric stand-up lift (SUL) during transfers for one resident. The resident had intact cognition, morbid obesity, hemiplegia, osteoarthritis, debility, and muscle spasms, and was non-ambulatory, using a wheelchair for mobility. Her MDS and care plan identified high fall risk and required substantial/maximal assistance for transfers, with use of a bariatric SUL and staff assistance. A PT evaluation documented left hemiplegia, inability to use the left hand to hold the lift, limited left knee extension due to pain, and total dependence for transfers, though she could maintain position in the sling with her left arm extended laterally and use her lower extremities to attain a partial stand for transfers. During a direct observation of a transfer to and from the toilet using the bariatric SUL, a nursing assistant did not engage the lift’s brakes at multiple critical points, contrary to the Alliance Stand Assist Lifts user manual and facility staff expectations. The NA opened the legs of the lift, placed the sling and belt around the resident, and attached the sling loops without applying the brakes. The NA then raised the resident from the wheelchair while the resident held the hand grip only with the right hand, with the left arm positioned straight back and the resident’s body slouched, knees bent, and buttocks appearing to hang from the lift. The NA moved the lift into the bathroom, positioned the resident over the toilet, lowered her onto the toilet with her feet on the platform and still attached to the lift, and left the resident alone in the bathroom without engaging the brakes and with the resident remaining hooked to the lift. When the resident signaled she was finished, the NA returned and again operated the lift without consistently using the brakes. The NA lifted the resident from the toilet without opening the legs of the lift, pulled her away from the toilet, completed perineal care, and then moved the lift out of the bathroom. The NA opened the legs of the lift to clear the wheelchair and lowered the resident back into the wheelchair without engaging the brakes. At no point during the observed transfer did the NA ask the resident about using the brakes, and the resident did not request that the brakes be engaged. Interviews with the resident and multiple staff further described the circumstances leading to the deficiency. The resident reported that she relied on the stand lift for bathroom transfers and felt some newer staff lacked knowledge and transferred her too quickly, prompting her to ask them to slow down for her safety. The NA stated she had been educated to use the SUL brakes before hooking the resident to the lift and while lifting, and acknowledged that brakes should have been engaged before lowering the resident onto the toilet and while the resident remained attached to the lift. She reported that this resident did not like the brakes engaged and felt "trapped," and admitted she did not follow her training with this resident despite understanding that failure to use brakes could allow the lift to move and cause injury or a fall. Additional interviews with an RN, restorative aide, clinical engineering, the administrator, and the DON confirmed that facility expectations and training required brakes to be applied when the lift was positioned in front of the resident, while sling loops were attached, and while the resident was being lifted or lowered, with brakes released only when moving the lift from one location to another. Staff also stated that if a resident remained attached to the lift, such as while on the toilet, the brakes should remain locked, and staff were expected to remain in the room to help prevent an accident. The Alliance Stand Assist Lifts user manual specified that after opening the base to go around the chair, brakes on both rear casters should be applied before positioning the resident’s feet and knees, attaching sling straps, and pressing the up button, with brakes released only after the resident’s body had completely left the chair and the transfer was to proceed. The observed practice with this resident did not follow these manufacturer instructions or the facility’s stated expectations for safe lift use.
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