F0689

G

Resident Fall and Femur Fracture During Mechanical Lift Transfer

Wewoka, Oklahoma Survey Completed on 01-23-2026

Penalty

Fine: $17,215

Summary

The facility failed to ensure a resident did not fall from a mechanical lift during a transfer, resulting in a fall and injury. The facility had a Safe Lifting & Mechanical Lift Policy dated 01/01/25 that required use of proper sling and equipment, two trained staff for transfers, and adherence to manufacturer instructions. The resident’s care plan for activities of daily living, dated 10/30/25, specified the need for a mechanical lift for transfers, and a quarterly assessment dated 12/31/25 documented that the resident was cognitively intact with a BIMS score of 15 and was dependent on staff for mobility. On 11/13/25, a late entry nursing progress note recorded that an LPN found the resident on the floor under the mechanical lift, with the resident complaining of pain all over, and the resident was sent to the emergency room for evaluation.

A hospital imaging report from the same day showed a nondisplaced fracture deformity of the distal femur in the resident’s right leg. A facility incident report dated 11/14/25 documented that the resident fell from a mechanical lift while being transferred by two CNAs. The resident’s fall care plan, dated 11/17/25, stated that the resident had been up in a mechanical lift when a sling loop came off the lift, causing the resident to fall to the floor toward the right lower corner of the sling, and that the resident was sent to the hospital for evaluation and treatment. CNAs interviewed later stated they were responsible for inspecting the lift before use, ensuring the resident was correctly positioned in the sling, and confirming that hooks or straps were properly secured. The administrator identified that 19 residents in the facility were dependent on mechanical lifts for transfers and there was no documentation that quality assurance was involved in the process.