Improper Mechanical Lift Positioning Causes Tipping Incident During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical lift transfer for a resident, resulting in the lift tipping during a bed transfer. The resident had end stage renal disease, a right below-knee amputation, bilateral lower extremity range of motion impairment, and muscle weakness. An annual MDS showed the resident was cognitively intact but required substantial to maximal assistance with transfers. The care plan documented a need for two-person assistance and use of a mechanical lift for transfers due to an ADL self-care deficit related to the amputation. On the day of the incident, two nurse aides were transferring the resident from a wheelchair to the bed using a mechanical lift. Manufacturer instructions for the lift specified that, for bed transfers, the lift legs should be positioned under the bed, widened for stability, and that staff should not push or pull on the lift arm or the patient. Contrary to these instructions, the lift was positioned beside the bed with the legs parallel to the bed rather than horizontally underneath it. During the transfer, one aide was on the side of the bed with the lift, and the other was on the opposite side attempting to position the resident over the center of the bed. According to interviews and the subsequent reenactment, before the lift was correctly positioned with its legs under the bed, one aide began pulling on the lift sling to center the resident over the bed. This action, combined with the improper positioning of the lift legs, caused the lift to tilt sideways. As it tipped, the arm of the lift struck one aide in the chest and came to rest on the resident’s left leg/knee while the resident was approximately two inches above the mattress. The resident, the aides, and the former DON all reported that the resident was then lowered onto the bed and had no complaints of pain or visible injury at that time. An x-ray of the resident’s left knee later showed an intact knee arthroplasty with no acute fracture or injury. The facility’s investigation, including statements from the aides and a reenactment, confirmed that the mechanical lift had been placed with its legs parallel to the bed instead of under it and that the aides were pulling on the lift sling to position the resident, both of which were inconsistent with the manufacturer’s instructions. The former DON stated that the lift legs should have been placed horizontally under the bed and widened to provide stability before attempting to position the resident, and that staff should not have been pulling on the lift sling. These actions and inactions directly led to the lift tipping during the transfer, constituting the unsafe transfer and accident hazard cited in the deficiency. Subsequent interviews with the resident and involved staff corroborated the sequence of events. The resident recalled the lift tipping sideways during the transfer, the lift arm striking the aide, and coming to rest on his left knee while he was slightly above the bed, after which he was placed onto the mattress without pain or injury. Both aides described the lift tipping as they attempted to center the resident over the bed, with one aide specifically attributing the tilt to the lift being off balance due to incorrect positioning and pulling on the sling. These consistent accounts, along with the manufacturer’s instructions and the facility’s own findings, establish that the improper positioning and handling of the mechanical lift during the transfer led to the cited deficiency in maintaining a safe environment and preventing accidents.
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