F0689

G

Failure to Use Two‑Person Assist During Sit‑to‑Stand Lift Transfer Resulting in Femoral Fracture

Chicago, Illinois Survey Completed on 02-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain resident safety during a mechanical sit‑to‑stand lift transfer and to provide the required two‑person assistance for a dependent resident at high risk for falls. The resident was an older adult with a history of multiple fractures, falls, spinal stenosis, polyosteoarthritis, bilateral artificial knee joints, generalized muscle weakness, reduced mobility, and need for assistance with personal care. The resident’s MDS documented functional limitations in range of motion in one upper extremity and both lower extremities and coded the resident as dependent for transfers, meaning assistance of two or more helpers was required. The care plan and a fall risk evaluation identified the resident as high risk for falls, with impaired physical mobility and prior fall during transfer.

On the morning of the incident, a CNA (V8) attempted to transfer the resident from bed to wheelchair using a mechanical sit‑to‑stand lift without a second staff member present. V8 reported that she applied the belt/sling, tightened it, attached the hooks, positioned the resident’s feet on the lift base, and locked the wheelchair nearby. As the lift began to raise the resident from the bed, the resident jerked or threw herself forward, causing her buttocks to slide off the bed while still attached to the lift, and her feet to come off the foot base. V8 attempted to lower the resident back toward the bed, but the resident’s buttocks slid off the bed and one foot came off the base, with toes touching the floor and the resident sliding forward. V8 then lowered the resident fully to the floor while the resident’s legs were twisted underneath her, with the right leg bent inward and tucked under the body as the resident came to rest seated on her buttocks.

After lowering the resident to the floor, V8 left to get help and returned with another CNA (V10). Both CNAs observed the resident on the floor in a seated position with legs twisted underneath her, and the resident was screaming and complaining of pain in her leg and knee. They manually lifted and slid the resident back into bed. Nursing documentation by an LPN (V9) noted that during the sit‑to‑stand transfer the resident threw herself forward, removed her foot from the base, placed one leg behind the other, and that the CNA had to lower the mechanical lift, resulting in the resident sitting on her legs, with both feet later observed pointed outward and a small skin tear on the anterior right calf and complaints of right lower extremity pain. The resident was subsequently sent to the hospital, where the admitting diagnosis communicated to the facility was a right periprosthetic femoral shaft fracture/hip fracture, attributed by facility staff and the medical director to the fall to the floor during the sit‑to‑stand transfer.

Multiple staff interviews confirmed that facility practice and expectation were that two staff members should assist with mechanical lift transfers, including sit‑to‑stand lifts, particularly for dependent residents. V8 acknowledged that staff were instructed to use two people with lifts but stated she had been using the sit‑to‑stand lift alone with this resident because help was not always available and she had not previously had problems. Other CNAs and the therapy director stated they always or usually used two staff for sit‑to‑stand transfers and believed that having a second staff member present could have helped prevent the resident from sliding off the bed or being injured. The DON reviewed the resident’s MDS coding for dependence in transfers and stated that, by definition, the resident should have had at least two staff assisting with the sit‑to‑stand lift, and that the event met the facility’s definition of a fall as a change in plane resulting in landing on the floor.

The DON further stated that, based on her understanding of the incident, the resident’s feet became tangled when V8 was trying to fix their position, and when the lift was lowered, the resident’s legs buckled, likely causing the injury. The DON indicated that V8 should have pulled the sit‑to‑stand lift upward instead of downward, as lowering it placed the resident’s weight on her legs while they were tangled underneath her. The therapy director and medical director both stated that when a resident is dependent for mobility and transfers, two staff members should be present during mechanical lift transfers, and they understood that the resident’s fracture occurred when she fell to the floor during the sit‑to‑stand transfer. The facility’s Safe Lifting and Movement policy stated that it was intended to protect the safety and well‑being of staff and residents and promote quality care through appropriate lifting techniques and devices, and the facility’s fall policy defined falls as downward displacement of the body to the floor or ground, including injurious falls where physical injury occurs.