F0689

G

Failure to Use Two-Person Assist for Sit/Stand Lift Transfer Resulting in Fracture

Fall River, Massachusetts Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe mechanical lift transfers and adequate supervision for a dependent resident who required a Sit/Stand Lift with two staff assisting for all transfers. Facility policy, revised in May 2025, required that two staff members be utilized for all mechanical lift transfers, including sit-to-stand lifts, and that staff maintain compliance with safe handling and transfer practices. The resident’s care plan, Resident Care Card, and an occupational therapy recertification and updated therapy plan dated 12/29/25 all documented that the resident was dependent for transfers, required a Sit/Stand Lift for all transfers, and needed moderate to maximal assistance of two staff members.

The resident, admitted in March 2024, had diagnoses including cerebral palsy, embolism and thrombosis of deep veins of the left lower extremity, muscle weakness, hypertension, hyperlipidemia, major depressive disorder, osteitis, and a wedge compression fracture of the fifth lumbar vertebra. A quarterly MDS showed the resident was cognitively intact (BIMS 15) but dependent on staff for transfers. Therapy staff, including the COTA and OT, confirmed in interviews that prior to the fall the resident had experienced functional decline, had weak lower extremities, and required a Sit/Stand Lift with maximal assistance of two staff members for all transfers.

On the evening of 01/01/26, CNA #1, an agency CNA with 18 years of experience, transferred the resident using a Sit/Stand Lift without another staff member present in the room, despite knowing that two staff were required for such transfers and having been informed at shift report that the resident required two-person assistance. During the transfer, the resident let go of the hand supports, slid out of the sling, and fell to the floor, subsequently complaining of left ankle pain. The facility’s HCFRS report and hospital ED documentation indicated the resident sustained fractures of the distal left tibia and fibula and was placed in a short leg fiberglass splint. The resident reported that previously there had always been two staff present during Sit/Stand Lift transfers, and another CNA stated she had offered to assist but was never called. Nursing staff interviews and progress notes corroborated that the fall occurred during a Sit/Stand Lift transfer and that the transfer had been performed by CNA #1 without the assistance of another staff member, while the DON was unable to clearly state the facility’s specific policy for Sit/Stand Lift staffing at the time of the survey.