F0689

G

Failure to Provide Safe Mechanical-Lift Transfer and Supervision Resulting in Hip Fracture

Charlotte, North Carolina Survey Completed on 01-28-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to provide a safe transfer and adequate supervision for a dependent resident who required a mechanical lift for all transfers. The resident had a history of cerebral infarction with left hemiplegia and hemiparesis, was cognitively intact, used a manual wheelchair, and was care planned as dependent on staff with a requirement for 2-person assistance and a mechanical lift for all transfers. On the evening of the incident, the resident was in a wheelchair with a lift pad underneath and was incontinent of urine, leaving both the pad and pants soaked. Nurse Aide (NA) #1 reported that she was repositioning the lift pad while standing beside the wheelchair when the resident and the pad slid from the wheelchair to the floor.

Nurse #1, who was down the hall administering medications, heard the resident yelling for help and found the resident on the floor in front of the wheelchair with NA #1 present. Nurse #1 observed that the lift pad remained in the wheelchair and was soaked with urine, and the resident complained of severe left hip pain and had an abrasion on the left lower leg. Unsure if it was safe to use the mechanical lift to move the resident from the floor to the bed, Nurse #1 and three staff members manually lifted the resident into bed. Pain medication was administered but was ineffective, and the on-call provider was notified, after which the resident was sent to the ED for further evaluation.

There were conflicting accounts regarding how the fall occurred. NA #1 stated that the lift pad was not yet attached to the mechanical lift and that the lift itself was in the doorway, while she repositioned the pad under the resident in the wheelchair. She denied that a lift strap broke and stated she typically hooked the sling to the lift before obtaining a second staff member when performing mechanical lift transfers. The EMS prehospital report, however, documented that facility staff reported a witnessed fall from a mechanical lift when a strap on the lift pad broke, and the resident confirmed to EMS that he fell from the lift, striking his head on the lift mast and his left leg on the bed before landing on the floor. ED records also documented that the resident was being transferred with a mechanical lift when a strap on the lift pad broke, resulting in a fall of approximately two feet and a nondisplaced greater trochanteric fracture of the left femur.

In a subsequent interview, the resident stated that after calling for assistance with incontinence care, NA #1 was lifting him from the wheelchair with the mechanical lift when he heard fabric ripping and the left front strap of the lift pad broke, causing him to fall about two feet to the floor, hitting his head on the lift and his left leg on the bed before landing on his left side. He reported severe hip and tailbone pain following the fall. The resident also stated that the lift pad that broke was labeled with his name in black marker and that he had not seen it since the incident. Other staff, including another NA and the laundry aide, confirmed that the resident had a lift pad labeled with his name but reported they had not seen it in the room or laundry that week. The DON later stated that NA #1 should not have attempted to reposition the lift sling under the resident without a second person present to ensure safety, and the Administrator acknowledged that NA #1 was attempting to reposition the soaked lift pad when the resident slid from the wheelchair to the floor.