The Illinois Department of Health has cited and fined Goldwater Care Danville when, according to state investigators and facility records, a certified nursing aide performed a mechanical lift transfer by herself rather than with the two staff members required by facility policy, and without inspecting the lift sling beforehand as the manufacturer and the facility both require. The sling broke while the resident was suspended in the air, and she fell to the floor and struck her head, sustaining a comminuted, displaced and impacted fracture of her left shoulder and a pocket of blood between her skull and scalp.
The facility’s own transfer policy classified mechanical lift transfers as requiring two caregivers and directed that lift equipment undergo routine maintenance checks by nursing and maintenance staff to remain in good working order. The requirement to inspect the sling before each individual use appears in the manufacturer’s manual and was confirmed by the facility’s own nursing leadership. The manufacturer’s instruction manual for the full body sling carried an explicit warning: “Carefully inspect the sling before each use for wear and damage to seams, fabric, straps and strap loops. Torn, cut, frayed, or broken slings can fail, resulting in serious personal injury to the user.” The Director of Nursing confirmed to investigators that staff are required to inspect slings before each use and that two staff members are required to operate the mechanical lift, and that any sling with a problem should be taken out of service and reported to her. The Administrator told investigators that staff are expected to use two assists for mechanical lift transfers and to inspect slings before every use.
According to the citation, the aide was transferring the resident from her wheelchair to her bed using the mechanical lift. The resident’s roommate, who witnessed the transfer, told investigators that both she and the resident told the aide that two staff members were required for mechanical lift transfers, but that the aide insisted she could do the transfer alone. The roommate further told investigators that, after the resident was elevated in the sling, the aide pulled on the sling and the sling then broke.
The sling gave way while the resident was suspended. The facility’s incident report documents that she was found on the floor on top of the mechanical lift legs, lying on her left side with her face pressed against the floor and her legs extended outward, with redness and bruising to the right side of her face and a visible deformity of her left arm. The aide reported that the resident struck her head on the roommate’s table during the fall.
She was transported to the hospital by ambulance. Imaging documented a comminuted, displaced and impacted fracture of the proximal left humerus involving the surgical neck and extending to the greater tuberosity, along with a small subgaleal hematoma — a collection of blood between the skull bone and the scalp — over the right side of her forehead. A CT scan found no underlying skull fracture and no bleeding inside the skull. The hospital record noted she was taking Eliquis, a blood thinner, for atrial fibrillation at the time she struck her head. Her daughter told investigators the resident was dropped from the lift while being transferred by one staff member and sustained a broken shoulder along with cuts and bruises to her face.
The aide acknowledged to investigators that she did not inspect the sling before beginning the transfer and that she was alone in the room. The Assistant Director of Nursing, who was called to the room, said the sling strap had broken while the resident was elevated, and that when she inspected the sling afterward, the hook on it had split in half. She confirmed the resident had been transferred by only one staff member and that facility policy requires two for all mechanical lift transfers.
The day after the fall, the facility held a quality assurance meeting on the incident, audited all slings in service, educated licensed and certified nursing staff on its fall prevention, incident, and mechanical lift transfer policies, educated laundry staff on the mechanical lift sling inspection log, and began auditing whether residents were being transferred with the appropriate equipment and appropriate number of staff.
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