F0689

G

Failure to Safely Use Mechanical Lift During Transfer Resulting in Resident Fall and Spinal Fracture

Rockford, Illinois Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe transfer and adequate supervision during the use of a sit-to-stand mechanical lift, resulting in a resident fall and injury. The resident involved was cognitively impaired and care planned as being at risk for falls due to impaired cognition, obesity, and impaired balance. According to the incident report and staff interviews, two CNAs used a sit-to-stand lift to transfer the resident from bed to wheelchair. After the resident was placed in the wheelchair, one CNA left the room, even though the resident remained attached to the lift via a strap around his back. As the remaining CNA began to unhook the back strap from the lift, the resident leaned or laid back in the wheelchair, causing the wheelchair to flip backwards and the resident to land directly on his back.

The facility’s Assistant DON stated that facility practice requires two staff members to remain with the resident until the resident is completely unhooked from the sit-to-stand lift and securely seated, with one staff operating the lift and the second stabilizing the resident and wheelchair. The facility’s written policy on “Safe Lifting and Movement of Residents, Including Mechanical Lifts” requires at least two CNAs for mechanical and stand lift transfers to safely move residents. In this incident, no one was holding the resident or the wheelchair while the strap was being disengaged, and one CNA had already left the room, contrary to facility expectations and policy. Following the fall, the resident complained of back pain over the next two days and was subsequently sent to the hospital, where a CT scan showed an acute, unstable hyperextension fracture of the eighth thoracic vertebra, attributed to the fall.