Failure to Ensure Competent Mechanical Lift Use Resulting in Resident Fall and Fractured Clavicle
Summary
The deficiency involves the facility’s failure to ensure that nursing staff, including CNAs and nursing leadership, possessed and demonstrated the competencies and skills necessary to safely perform mechanical lift transfers. A cognitively intact female resident with cerebral palsy, significant mobility limitations, muscle weakness, contractures, and a high fall risk score required two-person assistance with a mechanical lift for transfers per her care plan. Her care plan also directed staff to ensure mechanical lift straps were secure, intact, and that all straps were in place before transfer. Despite these requirements, the resident was transferred in the early morning hours by a CNA who did not follow proper sling attachment procedures. During a mechanical lift transfer from bed to chair, the CNA attached the lift sling to the handling strap instead of the designated sling attachment loop. The resident fell from the lift during this transfer and was found on the floor on her back. She initially denied pain, and no immediate skin discoloration was observed, but later developed bruising and pain in the left shoulder. X‑ray and CT imaging confirmed a fractured clavicle. The resident reported that usually two staff assisted with mechanical lift transfers, but on the day of the fall she believed only one CNA performed the transfer and that the CNA was attempting to get her out of bed early without obtaining a second staff member. She also reported that after the incident, a new sling used for transfers caused her significant pain in her right leg during each transfer, and she did not feel safe when that sling was used, although she had not reported this concern to the facility. Interviews and observations revealed broader competency failures beyond the single incident. The Administrator identified the root cause of the fall as staff error related to improper sling attachment. The DON was unable to demonstrate proper mechanical lift use, did not lock the lift wheels, did not correctly position the sling, and could not clearly explain required safety measures or the system to ensure proper lift use, sling inspection, or frequency of equipment checks. The DOR, who provided an in‑service on mechanical lifts after the incident, stated he had not been trained on the specific lifts and slings used in the facility, was unfamiliar with manufacturer models and sling compatibility, and had not used the facility’s mechanical lift competency and evaluation checklist. Multiple CNAs and nurses reported they had been in‑serviced on mechanical lift transfers but denied completing any competency validation and were unable to clearly explain or demonstrate proper mechanical lift and sling use during surveyor observation. Record review showed no documentation that CNAs or other direct care staff, including the DON, had demonstrated competency in mechanical lift transfers prior to performing resident care, and there was no structured system to verify staff competency or to identify which residents required mechanical lift transfers. During an observed transfer of the same resident by two CNAs, staff again failed to demonstrate proper mechanical lift technique. They did not ensure the lift wheels were unlocked prior to sling attachment and did not center the sling under the resident before transferring her from chair to bed. The resident reported pain associated with improper positioning during this transfer. Staff interviewed during the survey could not clearly explain required safety measures for mechanical lift use. These findings, combined with the lack of documented competencies, unclear responsibility for sling and lift inspection, and leadership’s inability to describe or demonstrate safe transfer procedures, showed that the facility failed to ensure nursing staff had the appropriate competencies and skill sets to safely perform mechanical lift transfers, resulting in a resident fall with a fractured clavicle and placing other residents who required mechanical lift transfers at risk for serious injury. An Immediate Jeopardy was identified related to this deficiency, based on the lack of competency validation and improper sling attachment that led to the resident’s fall and injury. The facility did not have documentation verifying that direct care staff or supervising nursing staff had demonstrated competency in mechanical lift transfers prior to performing resident care, and there was no record identifying the number of residents requiring mechanical lift transfers. Leadership interviews showed that the Administrator, DON, and DOR were unclear about training systems, competency tracking, and responsibility for equipment inspection. These conditions contributed to the improper use of the mechanical lift and sling that caused the resident’s fractured clavicle and placed other residents requiring mechanical lift transfers at risk for serious injury, including fractures, head trauma, internal injury, or death, as stated in the report.
Removal Plan
- Administrator/DON/Corporate Nurse reviewed the Safe Handling of Resident Transfers policy.
- Assess resident; notify appropriate parties; send resident to hospital for further evaluation as indicated; schedule follow-up appointment as indicated; continue monitoring for injuries/changes in condition.
- Corporate Nurse to re-educate nursing staff directly involved in the resident’s fall before performing direct care on safe resident transfers using mechanical lifts, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
- Place manufacturer instructions for mechanical lift sling inspection on each mechanical lift for employee reference.
- Corporate Nurse to re-educate the DON and DOR on safe resident transfers using mechanical lifts, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
- DON/designee to review care plans for residents who use mechanical lifts to ensure appropriate transfer status is identified in the care plan.
- IDT to review new admissions in morning clinical meeting to identify transfer needs and care plan these needs.
- IDT to discuss residents with change in condition affecting mobility status and update transfer status and care plan as appropriate.
- Place care planned interventions including transfer status on the resident Kardex so direct care staff can view resident-specific needs.
- Educate nursing and therapy staff before performing direct care to review the Kardex to identify resident-specific needs.
- Corporate Nurse/Consultant Nurse to educate DON/ADON/Administrator on the facility orientation checklist for nursing staff; validate via facility mechanical lift competency checklist.
- Include mechanical lift/sling training at orientation for new nurses and nurse aides; complete training prior to staff transferring a resident using the lift/sling.
- Corporate Nurse, DON, DOR or designee to re-educate nursing staff and therapy staff before performing direct care on appropriate transfer and safe handling during mechanical lift transfers, emphasizing proper securing of lift pad straps and inspection of straps/condition per manufacturer instructions; validate via facility mechanical lift competency checklist.
- Administrator or DON to sign off that new nursing staff have completed the orientation checklist including validation of competencies prior to being moved from orientation status.
- DON/designee to audit mechanical lift transfers twice weekly for a specified period, then weekly for a specified period, then monthly for a specified period.
- Administrator to implement a QAPI PIP to gather/process information from monitoring rounds and report findings at the monthly QAA meeting.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to ensure a QMA had a current license while distributing meds to residents. Record review showed the QMA was scheduled and worked on multiple days across 3 resident units, but the licensure binder and Indiana License Registry showed the QMA's license had expired. The ED stated staff should not distribute meds with an expired QMA license and that the facility had no written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
A resident with urinary retention and BPH required a coude catheter, but when the catheter became obstructed, an LPN told the resident to wait until day shift for a change and did not notify the RN supervisor or seek help. Facility records showed no competency training, return demonstration, or skills validation for Foley or coude catheter care, and multiple nurses said they had not received facility-specific education or competency checks for coude catheter management.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Expired QMA License During Medication Distribution
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant had a current license while distributing medications to residents. A record review showed that QMA 3 was scheduled to distribute medications and had worked as a QMA on multiple days across three resident units from April through the review period. The facility's Employee Certification and Licensure binder showed that QMA 3's license had expired, and the Indiana License Registry website also indicated the license was expired. In interviews, the Executive Director stated that staff should not distribute medications with an expired QMA license and that the facility did not have a written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Lack of competency validation for coude catheter care
Penalty
Summary
The facility failed to ensure licensed nursing staff possessed and demonstrated the competencies needed to safely assess, manage, and provide care for residents requiring a coude catheter. Resident 9 was admitted with urinary retention and benign prostatic hyperplasia with lower urinary tract symptoms, and a care plan dated March 30, 2026, identified the need for a coude catheter. On May 7, 2026, nurse documentation and interview with the DON showed the resident’s coude catheter became obstructed during the night shift, and the LPN on duty told the resident he would need to wait until day shift staff arrived for the catheter to be changed. The DON stated the LPN reported she was not comfortable changing the coude catheter because of a lack of familiarity and experience with that type of catheter, and she did not notify the RN supervisor or seek assistance to ensure timely catheter intervention. Review of facility documentation titled Skilled Nursing Competency Training showed competencies listed for licensed practical nurses, including nephrostomy tubes and suprapubic catheters, but the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management, or coude catheter care and replacement. During interviews, four licensed nurses stated they had general catheter education in nursing school and prior experience with coude catheters at previous employers, but all reported the facility had not provided facility-specific education, training, competency evaluation, or skills validation related to coude catheter care, evaluation, insertion, replacement, or management. The DON was unable to provide documented evidence that licensed nursing staff had completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.
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