F0689

D

Failure to Ensure Safe Bed Care and Mechanical Lift Transfers for a Dependent Resident

Kokomo, Indiana Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision and safe equipment use during care and transfers for a dependent resident. Resident C had multiple medical diagnoses including COPD, CHF, hypertension, morbid obesity, and bilateral knee osteoarthritis, and was documented on the MDS as dependent on staff for transfers and substantially/fully dependent for bed mobility and toileting. Care plans identified self-care deficits and fall risk, with interventions such as use of a trapeze bar, assistance with transfers, non-skid footwear, and maintaining a safe environment. Despite these identified needs, the resident experienced several incidents during incontinence care and mechanical lift transfers.

In one incident, during incontinence care, the resident was turned toward the window while holding the overhead trapeze and fell from the bed. Documentation indicated the resident turned to her left side, her hand slipped from the trapeze, and she fell from the bed, sustaining a scratch to the right lower leg. The resident and her daughter reported that the bed was too small and that the resident was too close to the edge of the bed during care, leading to her rolling or sliding off. A CNA described the resident sliding off the bed into a split position between the bed and the window while the CNA was providing peri care. This occurred even though the resident had been care planned as at risk for falls and dependent for transfers and bed mobility.

In a separate incident, the resident was being transferred with a mechanical (Hoyer) lift when the sling strap broke and the resident fell to the floor. Three CNAs were involved in the transfer; one CNA reported the resident was lifted slightly off the bed when the stitching on the strap came loose, causing the resident to fall and hit her back and shoulder on the lift legs, with subsequent complaints of lumbar and back pain. Staff interviews revealed uncertainty about which sling pad was used and whether it was the correct weight limit for the resident. Observations showed staff using a large blue lift pad and declining the resident’s request to cross the leg straps, while the resident reported that staff had crossed the straps on multiple prior occasions and that she felt like she would slide out when the larger pad was used. A unit manager pulled a sling from storage that lacked a visible weight limit on the tag and stated she did not know why it was not labeled, and the facility had no policy on mechanical lift use, despite manufacturer guidance that correct sling size and application are critical to prevent accidents.

In an additional incident, during another mechanical lift transfer, the lift contacted the resident’s overhead trapeze bar, knocking it down so that it struck the back of the resident’s head and caused a bump. The resident reported soreness at the back of her head, and the Executive Director confirmed that the trapeze bar dropped and hit the resident’s head. Across these events, the facility did not ensure that the environment around the bed and trapeze was arranged to prevent contact with the lift, did not consistently ensure appropriate sling selection and labeling based on resident weight, and did not have a facility policy governing mechanical lift use, all contributing to repeated accidents during care and transfers for this resident.

The facility’s own "Accidents and Supervision" policy stated that residents’ environments would remain as free of accident hazards as possible and that each resident would receive adequate supervision and assistive devices to prevent accidents, with all staff involved in observing and identifying potential hazards. However, the repeated falls from the bed during peri care, the fall from the mechanical lift due to a broken sling strap, and the incident in which the lift knocked down the trapeze bar onto the resident’s head demonstrate that the facility did not adhere to these expectations for this resident. The survey findings are tied to Intake 2680656 and cite regulatory provisions 3.1-45(a)(1) and 3.1-45(a)(2).