F0689

G

Failure to Apply Ordered Hip Protectors and Incorrect Mechanical Lift Sling Use Resulting in Resident Fractures

Hollidaysburg, Pennsylvania Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that ordered protective devices were applied as care planned for one resident and failure to maintain an environment free of accident hazards during a mechanical lift transfer for another resident, resulting in falls with fractures for both residents. For Resident 2, the facility’s own policy on incidents and accidents required individualized preventive measures, including hip savers, for residents at high risk for falls. Resident 2’s quarterly MDS showed confusion, wandering, a history of falls, and dementia, and the physician’s orders and care plan directed that hip savers be worn at all times due to fall risk. Multiple witness statements from nursing staff and nurse aides on the night and day shifts indicated that the hip savers were reportedly in place during care earlier in the day, including during incontinent care, morning skin checks, and after a shower.

On the afternoon of January 22, 2026, Resident 2 was found on the floor on his left side between two nightstands in another resident’s room, with an open area on the left side of the head, an abrasion on the left upper arm, and a skin tear on the left elbow. The resident yelled out in pain when the left leg was straightened, and the leg could not be fully straightened due to pain. The facility’s investigation report documented that the resident had non-skid socks and hip savers on at the time of the fall, and that the resident had last been observed by staff at 3:15 p.m. and last toileted at 7:47 a.m. However, when Registered Nurse 5 responded to the fall and assessed the resident, she confirmed that the hip savers were not on the resident, contrary to the care plan and physician’s order, and she reported this to the Registered Nurse Supervisor. The Registered Nurse Supervisor also observed that the hip savers were not in place and, upon reviewing the clinical record, confirmed that hip savers were ordered and care planned to be on at all times. The resident was sent to the hospital and diagnosed with a left hip fracture.

For Resident 3, the deficiency centers on improper use of a mechanical lift and incorrect sling size and attachment during a transfer. Resident 3’s quarterly MDS documented cognitive impairment, dependence on staff for daily care needs, dependence with transfers, and diagnoses including Parkinson’s disease, dementia, and orthostatic hypotension. The care plan identified a potential for falls related to new environment, adjustment to nursing home placement, tremor, orthostatic hypotension, Parkinson’s, and impaired mobility, and specified that a full mechanical lift with a large sling size was to be used for all transfers. On the evening of January 19, 2026, staff informed the nurse that the resident had fallen from the mechanical body lift during a transfer for a shower. The nurse found the resident lying on the right side between the legs of the lift, with the head near the center post at the doorway, the lift legs in the closed position, the lift arm in a high position, and blood along the occipital region of the head and on the floor from a head laceration. The resident complained of headache, neck pain, and back pain and was later admitted to the hospital with a scalp laceration requiring staples, a closed head injury, and a fracture of the sixth thoracic vertebra.

Statements from the two nurse aides involved in the transfer indicated that the resident fell backwards out of the sling and hit the floor while they were getting him out of bed for a shower, and that the lift pad had been positioned up his back. A Registered Nurse who reviewed the sling after the incident observed that it was an extra-large sling with long leg straps that required crisscrossing between the legs before attachment to the lift, but the straps had been connected incorrectly, with the two right straps together and the two left straps together, and not crisscrossed. The Registered Nurse Supervisor later observed the extra-large sling on the resident’s bed, noting that the material and straps appeared in good condition. The facility’s investigative documents concluded that the fall occurred because the wrong sling size was used, and the Director of Nursing confirmed that the investigation substantiated that the nurse aides used an incorrect sling size per the resident’s care plan and that the leg straps were not crisscrossed as required.