F0689

D

Failure to Provide Two-Person Assist During Full Mechanical Lift Transfer

Kankakee, Illinois Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its policy requiring two staff members for a full mechanical lift transfer. A cognitively intact resident with quadriplegia C6-C7 incomplete, post laminectomy syndrome, muscle wasting, chronic venous insufficiency, cellulitis of the right lower leg, and a stage 4 sacral pressure ulcer required extensive assistance with ADLs, including dependence on staff for transfers. The resident’s MDS showed dependence for transfers, and the facility’s mechanical lift policy dated January 2026 stated that two staff members are required during a full body lift transfer. The facility’s Restorative RN and Interim DON both stated that the expectation is for two staff to assist when using the full mechanical lift.

The facility’s fall incident reports showed the resident had a witnessed fall on February 6, 2026, during a transfer at the bedside when the resident slid forward in the chair. A CNA’s written statement documented that the CNA transferred the resident to a motorized wheelchair and the resident started to slide out, leading the CNA to leave the room to get help. An LPN later reported seeing the CNA request assistance and, upon entering the room, observed the resident sliding out of the chair with legs extended on the floor. The mechanical lift was present, with the top of the sling attached to the lift hooks, but the bottom of the sling was not underneath the resident and not attached to the lift. The LPN reported that the CNA stated she had transferred the resident from bed to chair using the full mechanical lift by herself and had attempted to move the resident up in the chair with the sling when it came out from underneath the resident. The LPN also reported that, in the presence of the resident’s daughters, the CNA stated she could not find anyone to assist with the transfer.