Description of Event or Problem · 1
IT WAS REPORTED THAT, ON 4/18/97 TWO NURSE ASSISTANTS WERE ATTEMPTING TO TRANSFER A RESIDENT, WHO HAD THE FOLLOWING DIAGNOSIS, CVA WITH APHASIA AND LEFT HEMIPARESIS, HTN, CHF, OSTEOPOROSIS AND CONTRACTURES, FROM THE BED TO A CHAIR USING A HOYER LIFT. THE RESIDENT WAS RAISED OFF THE BED WITH THE LIFT, WHEN THE LIFT WAS MOVED TO REPOSITION IT TO LOWER THE RESIDENT INTO THE CHAIR THE RIGHT FRONT HOOK, WHICH SUPPORTS AND ATTACHES THE SLING TO THE LIFT BY MEANS OF A CHAIN, BECAME DISCONNECTED FROM THE SLING. THE RESIDENT FELL APPROX. 28 TO 30 INCHES TO THE FLOOR, LANDING ON HER BUTTOCKS AND FRACTURING RIBS THREE THROUGH EIGHT ON HER RIGHT SIDE. INSPECTION FOUND NO DEFECTS OR PROBLEMS WITH THE LIFT OR SLING. INSPECTION OF THE CHAINS AND HOOKS REVEALED ONE HOOK, THE ONE USED ON THE RIGHT FRONT, WAS SPREAD ABOUT 1/8 TO 1/4 INCH WIDER THAN THE OTHER THREE. INVESTIGATION OF THE INCIDENT INDICATES THAT THE RESIDENT WAS RAISED BY THE LIFT, LOWERED SLIGHTLY SUCH THAT THE BOTTOM OF THE SLING MAY HAVE BEEN TOUCHING THE BED, TO ALLOW FOR REPOSITIONING OF THE RESIDENT AND THEN RAISED AGAIN, AT THIS POINT THE RESIDENT FELL. A RE-ENACTMENT BY THE STAFF, INDICATES THAT THE HOOK MAY HAVE BECOME PARTIALLY UNATTACHED FROM THE SLING WHEN THE LIFT WAS LOWERED TO REPOSITION THE RESIDENT AND WHEN THE LIFT WAS RAISED AGAIN THE WEIGHT OF THE RESIDENT FORCED THE HOOK TO DISENGAGE FROM THE SLING. ON APRIL 28, 1997 THE RESIDENT DIED, TEN DAYS AFTER THE INCIDENT. THE IMMEDIATE CAUSE OF DEATH PER THE DEATH CERTIFICATE WAS RESPIRATORY FAILURE, THE UNDERLYING CAUSES NOTED WERE FLAIL CHEST AND FRACTURED RIBS THREE THROUGH TEN OF THE RIGHT RIB CAGE. IT WAS SUGGESTED THAT A CLOSING MECHANISM BE INCORPORATED ON THE HOOKS SUCH THAT MANUAL RELEASE IS NECESSARY TO REMOVE THE HOOKS FROM THE SLING, THUS PREVENTING ACCIDENTAL RELEASE. (THE IMMEDIATE CAUSE OF DEATH PER DEATH CERTIFICATE WAS RESPIRATORY FAILURE, UNDERLYING CAUSE FRACTURED RIBS/FLAIL CHEST).