F0689

K

Unsafe Mechanical Lift Transfer and Inadequate Elopement Supervision

Enid, Oklahoma Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a safe transfer for a dependent resident using a mechanical lift and failure to provide adequate supervision to prevent elopement for another resident. One resident with intact cognition, end-stage renal disease, lower extremity impairments, and dependence on staff for all transfers was being transferred from bed to wheelchair with a mechanical lift when the sling strap broke, causing the resident to fall. The resident’s quarterly assessment documented dependence for all transfers, but the care plan dated shortly after the incident did not contain a focus or interventions for transfers at the time the accident occurred. The facility’s transfer policy required staff to provide safe, effective transfer techniques and to utilize manufacturer guidelines for mechanical lifts, and a facility document on sling care required inspection of slings for wear, tears, and loose stitching after laundering.

During the transfer incident, a CNA reported going to the laundry room to obtain a sling because the resident’s usual blue sling was not available in the room. The CNA stated that slings in the laundry came in different sizes and that they selected a medium white sling based on their own judgment, guessing the size and not usually checking for sizes. The CNA further stated they had never been trained on how to determine sling size, did not know the white slings were disposable, and did not understand why such slings were hanging in the laundry room. While two aides were transferring the resident with the mechanical lift, the white sling broke on one side, and the resident fell from approximately three feet in the air, landing on the back of the head, both shoulders, both hips, and the left knee, and later being diagnosed with fractures of the right clavicle and left tibia. The resident reported experiencing significant pain, needing staff assistance with feeding due to the clavicle fracture, and feeling embarrassed and fearful of transfers.

The deficiency also includes failure to provide adequate supervision to prevent elopement for another resident with significantly impaired cognition, dementia with behavioral disturbances, and chronic kidney disease. This resident had been assessed twice as a moderate elopement risk, with elopement assessment scores of 19 and 16, and had a prior care plan focus for exit-seeking behavior that included interventions such as frequent visual checks, maintaining a behavior log, and analyzing triggers. However, after the facility implemented a new EHR system, the DON acknowledged that the existing elopement focus and interventions from the earlier care plan were not carried over, and the care plan was not updated following the elopement risk assessments. As a result, from mid-year until after the elopement event, the resident did not have a current care plan focus or interventions addressing elopement risk and increased supervision, despite being known by staff to watch doors and exit seek for several months. The resident subsequently eloped from the facility after another resident let them out, was discovered missing by a CNA, and was later found off premises near a church parking lot with scratches on the arms before being returned.

The facility is located on a busy two-lane main street adjacent to a golf course with ponds, and the elopement policy required documentation of incidents, nursing notes with accurate accounts of situations and outcomes, social services notes addressing emotional aspects, updated elopement risk assessments, and updated care plans. In the elopement case, a facility incident report documented that the resident was missing and later found during a search, and nursing notes recorded that the resident was discovered missing, that another resident admitted to letting them out, and that the resident was located and returned with scratches. However, the care plan revision following the elopement added a focus for elopement risk and some interventions such as staff awareness in common areas, redirection when fixated on exits, and signage on exits, but did not include interventions for increased supervision compared to the earlier care plan. The DON confirmed that the facility did not follow its policy to update the care plan after the elopement assessments showed the resident was a moderate elopement risk, resulting in a period where the resident’s known exit-seeking behavior and risk were not addressed in the active care plan.

Removal Plan

• Send Resident #7 to the hospital and return to the facility for continued treatment.
• Update Resident #7's care plan with interventions and focus to include transfers.
• Have the DON or designee perform audits of residents who require assistance with transfers using a mechanical lift and update care plans accordingly.
• Have the DON or designee reeducate nursing staff on choosing the proper slings and weight requirement.
• Do not allow staff who did not receive education to work until educated.
• Notify the medical director of the IJ.
• Hold a QAPI meeting with the medical director, the facility administrator, and director of nursing to review the plan of removal.
• Have the director of nursing track, trend, and analyze audit results and forward results of audits monthly to the QAPI Committee for review and/or action.