F0689

D

Improper Manual Floor-to-Wheelchair Transfer Without Mechanical Lift

Arlington, Texas Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and safe transfer techniques for a newly admitted resident with significant cognitive and functional impairments. The resident was an elderly male with dementia, anxiety disorder, chronic pain, and metabolic encephalopathy, admitted via EMS on a stretcher and requiring extensive assistance with ADLs. Admission and nursing notes documented that he needed two-person assistance for bed mobility, transfers, dressing, bathing, and hygiene, used a wheelchair most of the time, was unable to use devices or comprehend instructions due to poor cognition, and had poor decision-making ability requiring reminders, cues, and supervision. A fall risk assessment identified him as high risk for falls due to recent fall history, intermittent confusion, chair-bound status, inability to stand, and multiple medications contributing to fall risk. His care plan included two-person assistance for transfers but did not specify assistive devices.

On the day of the incident, the resident was observed sitting on the floor in the dining area in front of his wheelchair. An LVN ran to assist, assessed the resident on the floor, and found no evidence of injury. The LVN then directed two CNAs to transfer the resident back to his wheelchair. The CNAs placed a gait belt around the resident’s waist, positioned themselves on either side of him facing him, grasped the gait belt in the back, and simultaneously placed their forearms directly under his arm pits to lift him from the floor into the wheelchair. During this maneuver, the gait belt slid up the resident’s back, and the resident did not appear to assist in the transfer, resulting in the CNAs performing the full lift. The resident was then positioned near the nurses’ station, where he intermittently leaned forward as if attempting to stand, and staff verbally redirected him to remain seated.

Interviews with staff revealed uncertainty and inconsistency regarding appropriate transfer methods for this resident, particularly when he was unable to bear weight or assist. The LVN who responded to the fall believed the CNAs were supposed to “cup their arms under his” to lift him. Therapy and nursing leadership, including the OT, DOR, ADONs, and Regional RN, stated that residents should not be lifted under the arm pits and that a mechanical lift should be used when a resident cannot safely assist or when staff cannot safely lift with a gait belt alone. The OT specifically stated she would never go under a resident’s arms to lift and described alternative methods that avoid stress on the shoulders. Both CNAs acknowledged that lifting under the arm pits could injure a resident’s shoulders and that a mechanical lift is normally used when a resident cannot stand or bear weight, but they proceeded with the manual lift because they expected the resident to help and he did not. Review of CNA proficiency audits showed both CNAs had previously been deemed satisfactory in various transfer techniques, and review of the facility’s transfer policy showed it addressed gait belt use and two-person transfers but did not address procedures when a resident is unable to assist or bear weight.

Additional documentation and interviews indicated that the resident had a prior unwitnessed fall in the facility, was combative and agitated at times, did not call for assistance, and resisted redirection, leading to additional fall precautions such as a low bed, air mattress, and fall mat. The ADON reported that at admission he believed the resident was unable to bear weight and that the resident had not noticeably changed since admission. Multiple staff, including the DOR, ADON, and Regional RN, confirmed that staff were trained not to lift under the arm pits and that mechanical lifts should be used when manual lifting exceeded the capabilities of the resident or staff. Despite this, the CNAs manually lifted the resident from the floor using their forearms under his arm pits in combination with a gait belt, rather than using a mechanical lift, which constituted the failure to provide adequate supervision and appropriate assistance devices to prevent accidents.

The facility’s fall policy stated that staff must be trained in safe transfer techniques and proper body mechanics, and the transfer procedure referenced the use of a gait belt and two-person assistance but did not specify what to do when a resident could not assist or bear weight. Staff interviews also referenced that an ice storm had interfered with therapy’s timely evaluation of new residents, including this resident, which contributed to the lack of a therapy assessment at the time of the incident. Nonetheless, the existing nursing assessments and fall risk evaluation already documented the resident’s high fall risk, cognitive impairment, and extensive assistance needs. In this context, the decision by CNAs to lift the resident from the floor by supporting him under the arm pits, combined with the absence of clear policy guidance for non–weight-bearing residents in floor transfers, led to the cited deficiency for failure to ensure the resident received adequate supervision and appropriate assistance devices to prevent accidents.