Description of Event or Problem · 1
NURSING HOME RESIDENT WAS BEING TRANSFERRED BY AN ELECTRIC LIFTING DEVICE WITH TWO NURSE AIDES IN ATTENDANCE. EVENT OCCURRED IN RESIDENT'S ROOM. A NYLON SLING WAS POSITIONED UNDER THE RESIDENT, ACCORDING TO PROCEDURE, AND LOOPS ON THE SUPPORT STRAPS WERE ATTACHED TO THE LIFT PER PROCEDURE. AS THE LIFT WAS OPERATED TO RAISE THE PERSON AND TOOK ON PT'S FULL WEIGHT, ONE OF THE LOOPS ON A SUPPORT STRAP (4 STRAPS USED) DETACHED WHEN STITCHING SECURING THE LOOP TO THE STRAP SEPARATED, THEREBY CAUSING THE SUPPORT STRAP TO BE RELEASED. THE SUDDEN IMBALANCE IN THE LIFT TOSSED THE RESIDENT ONTO THE FLOOR FROM A HEIGHT OF APPROX 3 FEET. UPON EXAMINATION OF THE SLING IT WAS FOUND THAT ANOTHER SUPPORT LOOP'S STITCHING CAME APART WHEN TESTED BY HAND. THIS SLING WAS BRAND NEW AND HAD ONLY BEEN PUT INTO USE ON THE PREVIOUS DAY. SLING SHOWED NO SIGNS OF WEAR OR DEFECT, BUT AFTER EVENT IT WAS DETERMINED THAT THE STITCHING FOR THE TWO LOOPS HAD NOT GONE ALL THE WAY THROUGH THE NYLON FABRIC ON BOTH SIDES.