Neglect During Mechanical Lift Transfer Resulting in Fractured Humerus
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not following the resident’s care plan and by using defective equipment during a transfer, resulting in a fall and a fractured right humerus. The resident was an elderly female with dementia and severe cognitive impairment, assessed as high risk for falls. Her comprehensive care plan and Kardex in place at the time specified that she required two staff for transfers using a stand-up mechanical lift. Despite this, on the morning of 12/26/25, a CNA transferred the resident alone from bed to wheelchair using the stand-up lift. During the transfer, the CNA reported hearing a pop sound as the clasp unbuckled and the right strap came off the lift, causing the resident to fall to the floor and complain of right upper extremity pain with visible swelling. A stat x-ray later confirmed a fracture of the surgical neck of the humerus with greater tuberosity extension. The CNA stated she was new, believed the resident to be a one-person transfer based on prior practice, and admitted she did not review the care plan or Kardex because she only checked the Kardex for new residents. She also reported that one of the clips on the right side of the lift was missing, that she had noticed this on a prior date, and that she had used the same lift with the missing clip previously without incident. Interviews and observations further documented that the stand-up lift used in the incident had differing clip types on each side and that maintenance later found several lifts with missing clips/stoppers and replaced them, with no prior work orders or reports about missing clips before the fall. Nursing staff, including the unit manager who conducted the investigation, were aware that the resident was care planned as a two-person transfer with the stand-up lift, but the internal investigation focused on sling buckle malfunction and did not address the use of only one staff member for the transfer. Post-fall assessments by nursing staff and the MDS nurse confirmed that the resident sustained a fracture and experienced a significant change in condition, including increased dependence in ADLs and changes in transfer status, directly associated with the fall during the improperly conducted transfer.
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