F0689

J

Improper Mechanical Lift Use and Inadequate Supervision Resulting in Resident Fall and Clavicle Fracture

Houston, Texas Survey Completed on 02-27-2026

Penalty

Fine: $12,460

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and proper use of assistance devices during a mechanical lift transfer, resulting in a fall and injury to a resident. The resident was an adult female with cerebral palsy, abnormalities of gait and mobility, muscle wasting and atrophy, generalized muscle weakness, and joint contractures. Her MDS showed a BIMS score of 14, indicating no cognitive impairment, and a fall risk assessment score of 22, indicating high risk for falls. Her care plan identified her as at risk for falls related to limited mobility, weakness, and altered mental status, with a goal to remain free of falls and injuries. Interventions included use of a mechanical lift with two-person staff assistance for transfers and ensuring mechanical lift straps were secure, intact, and that the lift was charged before transfer.

On the date of the incident, the resident was being transferred from bed using a mechanical lift by CNA G, with conflicting accounts about whether a second staff member was present at the time of the transfer. The resident reported that only one staff member was performing the transfer initially and that a second CNA arrived after the fall to get the nurse. During the transfer, CNA G attached the mechanical lift sling to the handling strap instead of the designated sling attachment loop. The sling strap then broke during the transfer, causing the resident to fall from the lift to the floor. The resident immediately experienced pain and reported it to the nurse. The facility’s Administrator later determined through investigation that the root cause of the incident was staff error in attaching the sling to the wrong part of the lift.

Following the fall, the nurse on duty assessed the resident, who at first denied pain and showed no immediate discomfort or visible skin discoloration. The resident was found on her back on the floor with the sling under her body. The nurse was informed that the sling strap had broken during the transfer and that another sling was used to transfer the resident back to bed after the incident. Later that morning, the resident reported pain, and bruising was observed near the left shoulder. An X-ray performed at the facility revealed a fractured clavicle, which was confirmed by hospital imaging as a fracture of the distal end of the left clavicle. Interviews with the Administrator and DON showed they could not clearly explain how staff training on mechanical lift use was tracked, how competencies were validated, or who was responsible for inspecting slings and straps for safety or how often such inspections occurred. These actions and inactions led to the unsafe transfer, fall, and resulting clavicle fracture.

In addition, after the incident, the resident reported that the facility replaced the sling and that the new sling caused significant pain, described as a knife-stabbing sensation to her right leg during each transfer. She stated she did not feel safe when the new sling was used and had not notified the facility of this concern. The report notes that the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically citing the improper attachment of the sling by CNA G and the lack of clear systems for training, competency validation, and equipment inspection by facility leadership. An Immediate Jeopardy was identified related to this failure, and the facility remained out of compliance at a level of potential for more than minimal harm.

The DON stated he was responsible for ensuring nursing staff were skilled and knowledgeable about mechanical lift safety but was not aware if the DOR had been informed of the fall incident. He could not explain who was responsible for inspecting slings and straps or how often mechanical lifts and slings were inspected for safety. The Administrator stated that all direct care staff were responsible for ensuring mechanical lift slings were safe and used properly, and that the DON was responsible for ensuring all direct care staff were trained by the DOR, but he was not aware how the DON tracked training and compliance. These gaps in oversight and unclear responsibilities contributed to the failure to ensure safe mechanical lift transfers and adequate supervision for the resident.

Removal Plan

• Corporate Nurse will provide re-education to nursing staff directly involved in the resident's fall on safe resident transfers when utilizing mechanical lifts, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
• Manufacturer instructions for mechanical lift sling inspection will be placed on each mechanical lift for employee reference.
• Corporate Nurse will provide re-education to the DON and DOR on safe resident transfers when utilizing mechanical lifts, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
• DON/Designee will review care plans for residents who use mechanical lifts to ensure appropriate transfer status is identified in their care plan.
• IDT will review new admissions in the morning clinical meeting to identify transfer needs and care plan these needs.
• IDT will discuss residents with a change in condition affecting mobility status and update transfer status and care plan as appropriate.
• Care planned interventions, including transfer status, will be placed on the resident Kardex so direct care staff can view resident-specific needs.
• Corporate Nurse/Consultant Nurse will educate the DON/ADON on the facility orientation checklist for nursing staff; education validated via facility mechanical lift competency checklist.
• Corporate Nurse, DON, DOR or designee will re-educate nursing staff and therapy staff on appropriate transfer and safe handling of residents during mechanical lift transfers, emphasizing proper securing of residents with mechanical lift pad straps and inspecting straps for safety prior to use per manufacturer instructions; education validated via facility mechanical lift competency checklist.
• DON or designee will audit mechanical lift transfers.
• A QAPI PIP will be initiated to report on the monitoring and auditing procedures.
• All findings from the PIP will be presented at the monthly QAA meeting.
• Monitoring/auditing and reporting will continue.