F0689

G

Failure to Use Required Mechanical Lift and Report Assisted Fall Leads to Hematoma After Manual Transfers

Goldsboro, North Carolina Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were used during transfers, as required by the resident’s care plan and Resident Care Guide. The resident had dementia, ESRD on hemodialysis, diabetes, was cognitively intact, and was totally dependent on staff for transfers. Her care plan and Resident Care Guide, implemented and revised prior to the incident, specified that she required a one-person assist with a mechanical lift for all transfers, with a medium sling. She was also receiving Eliquis, an anticoagulant that increases the risk of bruising and bleeding, and had an as-needed order for oxycodone for pain.

On the day of the incident, the resident returned from dialysis around midday, ate lunch, and requested to be put to bed because she was tired and hurting, which staff reported was usual for her after dialysis. Nursing Assistant (NA) #1, who was passing meal trays, told the resident she would assist after meal service. When NA #1 later attempted to retrieve a mechanical lift, she found that the two lifts in her assigned section did not have any charge. NA #1 informed the resident she would have to wait longer because the lifts were not available, but the resident was adamant about being transferred to bed immediately. Around 2:45 PM, despite knowing from the Resident Care Guide that the resident required a mechanical lift for all transfers, NA #1 decided to accommodate the request and attempted a stand-pivot transfer from the wheelchair to the bed without using a lift.

During this attempted manual transfer, the resident’s legs gave out, she began to panic, and she put her full weight on NA #1, who then lowered her to the floor. NA #1 did not notify a nurse at that time and, instead of leaving the resident on the floor for assessment, manually lifted her from the floor back into the wheelchair by placing her arms under the resident’s arms and her knees against the resident’s knees. The resident appeared slumped in the wheelchair, and NA #1 pulled her more upright. NA #1 then called for help without disclosing the assisted fall. NA #2 and the Medication Aide responded; seeing the resident slumped and appearing at risk of falling from the wheelchair, they, together with NA #1, manually lifted the resident from the wheelchair to the bed without a mechanical lift, with two staff at the upper body and one at the legs. After being placed in bed, the resident complained of right shoulder pain and requested pain medication. Later that evening, a large, painful swelling was observed on the right upper chest, and hospital evaluation documented a large, tense right chest wall hematoma with active bleeding, ultimately diagnosed as an arterial hemorrhage requiring interventional radiology embolization and subsequent surgical hematoma evacuation. The Medical Director stated that the hematoma more likely resulted from how the resident was transferred, including pressure applied under the armpits, rather than from the fall itself.