Improper Sling and Harness Sizes Used for Mechanical Lift Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate sling and harness sizes were used with mechanical lift and stand devices for multiple dependent residents, contrary to their assessments and care guides. One resident with multiple sclerosis, dementia, weakness, and dysphagia was assessed as unable to safely bear weight and required a full body lift with a medium (yellow) sling; however, surveyors observed a large (green) sling under her in the dining room and in her room, and a nursing assistant confirmed the large sling had been used for transfers despite the care guide specifying a medium sling. Another resident with arthritis, reduced mobility, weakness, and severe cognitive impairment was assessed to transfer with a mechanical lift using a small (red) sling, but was observed seated on a large (green) sling in the dining room and had a large sling on her wheelchair in her room. Two nursing assistants confirmed they had transferred this resident using the large sling, acknowledged the care guide called for a small sling, and stated they typically used whatever sling was already in the room without reviewing the care guide prior to transfers. A third resident with dementia, weakness, unsteadiness on feet, and severe cognitive impairment was assessed as non-ambulatory and required transfers with a mechanical stand and a small (red) harness, but was observed being transferred from the toilet to bed using a medium (yellow) harness. The nursing assistant involved initially stated the resident should have a medium harness, then, upon reviewing the care guide, verified that a small harness was care planned and explained she used what was already in the room. Another nursing assistant stated that sling size was based on height and weight and that staff used the sling available on the unit. The assistant administrator stated that staff were expected to ensure the sling was placed properly, the lift was in good condition, and the sling/harness size was appropriate for the resident prior to transfers, and facility policy required employees to use mechanical lift devices in accordance with instructions and training.
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