SAINT CLOUD, FL - A resident at Terrace of St Cloud fell through a mechanical lift sling and struck her head on the floor after staff used the wrong type and size of sling during a transfer, according to a July 2024 state inspection that cited the facility for actual harm.
Resident Falls Through Lift Sling Opening
The incident occurred on July 4, 2024, when two certified nursing assistants attempted to transfer an elderly resident from her wheelchair to her bed using a mechanical Hoyer lift. The resident, who had been admitted with multiple serious conditions including dementia, atrial fibrillation, muscle weakness, and difficulty walking, required two-person assistance with a Hoyer lift for all transfers according to her care plan.
According to the inspection report, staff used a "shower or toilet" sling rather than the standard transfer sling required for bed transfers. This type of sling features an opening at the bottom designed to position a resident's buttocks over a toilet. When the CNAs began raising the lift arm, the resident slid feet-first through this opening and fell to the floor, striking her head.
A nurse responding to the incident documented finding the resident lying on the floor on the right side of her bed with a 2-centimeter laceration on the back of her head and blood visible from the wound. The resident was transported to the emergency room for evaluation.
Wrong Equipment Used Despite Written Protocols
The facility's own policy on mechanical lift use, reviewed as recently as February 2023, explicitly states that staff must "visually check the size of the sling to ensure it is not too large or too small." Investigation revealed multiple failures to follow this protocol.
In a witness statement provided to the Director of Nursing, one of the CNAs involved admitted he "didn't ensure the sling was the correct size for the resident nor did he know what the correct size was supposed to be." The other CNA reported that they did not notice the resident's buttocks were not properly positioned over the sling opening until they had already begun raising the mechanical lift arm.
The DON's subsequent investigation determined that the sling used was not only the wrong type but also too large for the resident. Following her interview with staff, she concluded that "the CNAs had incorrectly used a shower/toilet sling when they should have used a regular sling."
Medical Significance of the Incident
The fall carried heightened medical risks due to the resident's medication regimen. She was prescribed Eliquis 2.5 milligrams twice daily to manage her atrial fibrillation. This anticoagulant medication, while essential for preventing strokes and blood clots in patients with irregular heart rhythms, significantly increases bleeding risk from even minor injuries.
Head injuries in patients taking blood thinners require immediate medical attention because internal bleeding can occur and progress rapidly without obvious external symptoms. A CT scan, laboratory tests, and electrocardiogram performed at the emergency department were negative for acute diagnoses, and the resident returned to the facility later that evening.
Proper mechanical lift technique is fundamental to safe patient handling in nursing facilities. Each sling type serves a specific purpose: standard slings support the full body during bed transfers, while toileting slings with openings are designed exclusively for bathroom assistance. Using the wrong sling type fundamentally compromises the safety mechanism of the lift system.
Additionally, sling sizing must be verified before each use. An oversized sling allows patients to shift position during transfers, creating gaps through which they can slide. Industry standards require staff to confirm both sling type and size match the individual resident's care plan specifications before initiating any transfer.
Facility Response and Training Gaps
An interdisciplinary team meeting held on July 8, 2024, addressed the incident. The meeting notes documented that "the mechanical lift sling has been changed, as the prior sling was too large for her and allowed room to slip out."
Both CNAs involved received additional training following the incident. One CNA stated that after working with the Director of Rehabilitation, she received "one on one training on safe transfers." The other CNA acknowledged that after the training, "he realized he needed to check to make sure the resident had the correct type of sling and the correct size of sling before using the lift."
The inspection also revealed uncertainty about transfer procedures earlier in the day. The CNA assigned to the resident during the day shift reported being "unsure whether she used the Hoyer lift to get the resident up that day" and could not recall who assisted with the transfer. She indicated that if she had performed the morning transfer, she would have left a sling under the resident for the next shift to use.
Additional Issues Identified
The inspection documented concerns about equipment verification procedures and staff knowledge of individual resident care requirements. The incident highlighted gaps in ensuring staff were aware of specific sling specifications for each resident requiring mechanical lift assistance.
The deficiency was classified at the "actual harm" level, indicating the violation resulted in documented injury to a resident. This classification represents a serious finding that requires immediate corrective action from the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace of St Cloud, The from 2024-07-24 including all violations, facility responses, and corrective action plans.
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