F0689

D

Improper Manual Transfer Performed Instead of Required Mechanical Lift and Two-Person Assist

Athens, Texas Survey Completed on 02-13-2026

Penalty

Fine: $138,600

Summary

The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible and that residents received adequate supervision and assistance devices during transfers. Resident #1, a male with cervical disc disorder with myelopathy, Parkinson’s disease, dementia, cervical spinal cord injury, neurogenic bowel, and neuromuscular bladder dysfunction, had severe cognitive impairment with a BIMS score of 03 and functional limitations in all four extremities. His MDS and care plan documented that he was dependent for transfers and required a total/mechanical lift with two-person assistance for chair/bed and tub/shower transfers. The Kardex also reflected that he required total assist with a mechanical lift and two staff for transfers.

On 02/10/26, Resident #1 experienced a fall during a transfer when CNA DD attempted to manually transfer him from his wheelchair to his bed without using the required mechanical lift and without a second staff member. The incident form documented that CNA DD reported his grip was slipping during the manual transfer, so he lowered the resident to the floor and then sought help. The post-fall evaluation and CNA DD’s statement indicated that he did not check the Kardex prior to providing care and that he attempted a manual transfer because the resident did not have a mechanical lift pad under him. The DON later stated that it was possible to place a sling on someone while in the wheelchair, and that CNA DD acknowledged he had not checked the Kardex.

Interviews corroborated that the mechanical lift and two-person assist were the usual and expected method for transferring Resident #1 and that this was not followed during the incident. Resident #1 reported that the CNA initially said something was wrong with the mechanical lift, did not explain what was wrong, and then tried to lift him by hand, ultimately dropping him to the floor. Resident #2, the roommate, stated he heard a loud noise, a scream, and then heard the CNA call for help, and confirmed that typically a mechanical lift was used for Resident #1’s transfers and that the lifts were working at the time. RN O stated that CNA DD told her, “I dropped him,” and confirmed that Resident #1 was normally a mechanical lift transfer and that the CNA did not use the lift. A family member’s video-recorded conversation with a nurse further reflected that the nurse acknowledged the CNA should have had two people and that a mechanical lift was available at the time of the transfer.

The facility’s mechanical lift policy, last revised 09/08/23, stated that the purpose of the lift was to move immobile patients for whom manual transfer poses potential for resident injury and noted that, although one person can operate most models, it is advisable to have two staff members present to stabilize and support the resident. Despite this, CNA DD attempted a manual, one-person transfer of Resident #1 without the mechanical lift and without a second staff member, contrary to the resident’s care plan, Kardex instructions, and the facility’s policy. This sequence of actions and inactions led to Resident #1 being lowered to and found on the floor next to his bed, constituting the accident event underlying the cited deficiency.