F0726

K

Failure to Ensure Competent Mechanical Lift Use Resulting in Resident Fall and Fractured Clavicle

Houston, Texas Survey Completed on 02-27-2026

Penalty

Fine: $12,460

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.