Key points:
- Providers must ensure there is clear oversight for maintenance checking and servicing of equipment used in aged care.
- Records of maintenance schedules should be kept for all equipment.
- Specific use limitations should be adhered to, for example weight or load limits.
This alert is in response to a recent Coronial report from Tasmania where an aged care resident was severely injured and subsequently died from a fall due to hoist failure.
I would like to remind providers of their obligations to ensure there is clear oversight for maintenance checking and servicing of equipment used in aged care.
Records of maintenance schedules should be kept for all equipment. It should also be clear who is responsible to monitor checking dates, arrange for checking/servicing of equipment according to manufacturer recommendations, scheduling technician visits, and ensuring that follow up actions occur.
Specific use limitations must also be adhered to e.g. weight or load limits.
Relevant equipment includes:
- Mobility and lifting devices
- Electrical, gas, air conditioning and heating equipment
- Medical monitoring and treatment equipment and devices
- Fire equipment and mechanisms such as alarms, extinguishers and fire doors
- Any other equipment or devices with the potential to become ineffective or to put safety of consumers and staff at risk.
In the coronial case, it was identified that the failure was a result of a crucial nut and bolt combination at the join of the load-bearing lifting arm to the frame. They also identified that an adhesive or split pin arrangement could have potentially prevented the failure, and suggested that when looking at hoists in particular, technicians be made aware of the details. Please ensure your hoist technicians are aware of this.
The Coroner made the following recommendations:
- I recommend that all facilities using mobility hoists review their maintenance schedules to ensure that they are serviced at intervals which are appropriate to detect and prevent failure of the components.
- I recommend that technicians responsible for servicing mobility hoists use thread locking adhesive (such as Loctite) and/or split pins to provide additional security to critical, load-bearing nuts and bolts.
Please share this alert with management and relevant staff within your service.
Dr Melanie Wroth MB BS, FRACP
Chief Clinical Advisor
