F0689

G

Failure to Follow Care-Planned Mechanical Lift Transfers Resulting in Ankle Fracture

Conrad, Iowa Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow the care-planned transfer method requiring the use of a full-body mechanical lift with two staff for a resident, resulting in an ankle fracture. The resident had a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses including heart failure, chronic kidney disease, muscle weakness, and difficulty walking. The MDS, Care Plan Task, and Kardex all documented that this resident required a full-body mechanical lift with assistance of two staff for all transfers. Despite this, staff interviews and the facility’s own investigation revealed that CNAs at times performed manual two-person transfers instead of using the mechanical lift, including transfers to and from the commode and recliner.

On one occasion, two CNAs attempted to place the mechanical lift sling under the resident while she was on the commode but were unable to do so and proceeded with a manual transfer to a recliner, which one CNA described as very hard, awkward, and a struggle, during which they became tangled with the resident’s legs. The resident later reported that her feet got tangled when she went to her chair the previous night and subsequently complained of severe right ankle pain, swelling, and inability to bear weight or move the ankle freely. The physician was notified, an x-ray was obtained showing a questionable right ankle fracture, and a physician progress note documented that the resident sustained an ankle fracture during a transfer. The facility’s investigation, including staffing review and staff statements, confirmed multiple instances where CNAs assisted this resident with two-person manual transfers instead of using the required mechanical lift, contrary to the facility’s Safe Resident Handling/Transfers Policy and the resident’s plan of care.