F0684

D

Failure to Follow Care-Planned Mechanical Lift Transfer Resulting in Tibia Fracture

Sandusky, Michigan Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure resident safety by not following care-planned interventions during a transfer to a wheelchair. A resident with Alzheimer’s disease, muscle wasting and atrophy, muscle weakness, need for assistance with personal care, and a right tibia fracture was admitted and later readmitted to the facility. The resident’s Minimum Data Set showed severely impaired cognition with a Brief Interview of Mental Status score of 0/15, and dependence on staff for transfers, bathing, dressing, and personal hygiene. The resident’s individualized plan of care required use of a mechanical lift (Hoyer lift) with a red-trim sling for transfers, with an assist of one person at the time of the incident.

On the morning in question, a CNA reported assisting the resident into her personal wheelchair prior to 6:00 AM using a two-person manual transfer instead of the required mechanical lift with the red-trim sling. This action deviated from the resident’s individualized plan of care, which clearly specified use of the Hoyer lift and sling, and the CNA had been appropriately trained on this requirement. The CNA could not recall who assisted with the transfer and reported that the resident did not complain of pain and that no accident or injury occurred at that time. The evening before, the resident had been transferred back to bed by a CNA and a nurse, and the sling used for that transfer had been soiled and sent to the laundry.

Later, at approximately 8:30 AM, staff notified the DON that the resident was complaining of pain in the right lower extremity, with deformity noted, and no fall, accident, or injury had been witnessed or reported. Diagnostic imaging at the hospital revealed an acute comminuted mildly displaced fracture of the distal tibial metadiaphysis and an acute mildly displaced fracture of the distal tibial diaphysis. Subsequent observations during the survey showed the resident sitting in a wheelchair with the right leg elevated in a cast and a red-trim mechanical lift sling positioned underneath her, with a mechanical lift available in the hallway. Interviews with laundry and CNA staff confirmed that there were sufficient mechanical lifts and appropriately colored slings available, and that staff were aware that transfer requirements were listed in the resident’s closet care plan. The facility’s failure occurred when the CNA did not follow the resident’s established transfer plan of care and used a manual transfer instead of the required mechanical lift and sling.