Fall During Transfer in EZ Stand

According to the MDH report, Rivers Edge fall occurred when the facility neglected the resident and used an EZ stand (stand – assist lift) without securing the sling causing the resident to fall during a transfer. The facility failed to document the fall nor intervention to prevent future falls.

The State Substantiated Neglect

The report continues that the MDH determined that neglect was substantiated. The facility was responsible for the maltreatment. The resident fell while in the EZ stand was in place when the sling became detached, but this fall was not recorded in the resident’s medical record. The sling became detached because of a missing safety latch and, while the specific EZ stand was taken out of service, the facility did not have a system in place to maintain equipment EZ stands(s) which continued to be in use. Additionally, the investigation found the facility continued to use an undersized sling during transfers which caused the resident discomfort approximately eight months after his admission to the facility. The EZ stand owned and used by this facility was not approved by the EZ stand manufacturer for use of the resident’s weight.

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