F0689

K

Failure to Provide Safe Mechanical Lift Transfers, Adequate Supervision, and Sufficient Staffing to Prevent Falls

Merkel, Texas Survey Completed on 02-16-2026

Penalty

Fine: $204,535

Summary

The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents for multiple residents at risk for falls. One resident with dementia, severe cognitive impairment, and a care plan requiring two staff for mechanical lift transfers was routinely transferred by a single aide using a mechanical lift. On one morning, the resident reported being dropped to the floor during a mechanical lift transfer performed by one nurse aide, who then pulled her back into the wheelchair and instructed her not to tell anyone. The resident later complained of pain in her left hip, leg, and foot, with internal rotation, redness, swelling, and inability to move the lower leg/foot, and was subsequently diagnosed with a distal femur fracture requiring surgery. The resident’s roommate, who had moderate cognitive impairment, stated she observed the aide alone transferring the resident with the mechanical lift, heard the aide exclaim, and saw both the resident and the lift on the floor, and further stated she had never seen two staff assist with that resident’s mechanical lift transfers.

The facility’s own records and staff interviews showed that the resident’s care plan required assistance by two staff for transfers using a mechanical lift, and the facility’s mechanical lift policy required at least two nursing assistants for safe use. The nurse aide involved stated she had never been trained by the facility on mechanical lift transfers, although she knew two staff were required, and the facility could not locate her orientation/evaluation checklist or any documented training regarding resident care. Another nurse aide on the same shift reported she had not received training on mechanical lift use and did not recall assisting with the transfer, while the LVN on duty denied assisting and reported having previously voiced concerns about aides transferring residents alone. The ADON stated that nurse aides could not perform transfers without a CNA or nurse and that nurses were supposed to supervise aides to ensure they did not perform tasks they were not trained in, but there was no evidence this supervision or training occurred for the aide involved.

The deficiency also includes failures related to supervision and staffing for two other residents at high risk for falls. One resident with heart failure, kidney disease, moderate cognitive impairment, and a care plan identifying high fall risk and the need for prompt call light response fell after using the call light for toileting assistance, waiting, then attempting to go to the bathroom alone, urinating on herself, slipping, and falling. At the time of this fall, timecards showed only one nurse aide was on duty as direct care staff; during observation, no staff were present in the hall or at the nurses’ station while the resident was on the floor with the call light activated, and a hospice aide not employed by the facility ultimately located staff. The aide on duty stated she was the only aide working, had difficulty getting everything done when working alone, and that being short staffed could lead to residents not getting the care they needed and could be considered neglect.

Another resident with colon cancer, muscle weakness, moderate cognitive impairment, and a care plan identifying high fall risk related to weakness experienced multiple falls over a period of time, including several without injury and two with injury, one resulting in multiple rib fractures and hospitalization. The care plan for this resident had not been updated with new fall interventions since several months prior, despite repeated falls documented in the incident log. Progress notes described falls in the bathroom and between the bathroom and room, with the resident attempting to get on the commode or reaching down to pick up a phone and losing balance. The resident’s family representative reported the resident was anxious and tried to get up on her own. Timecards showed that at the time of two of this resident’s falls on the same day, only one nurse aide was on shift as direct care staff. The ADON later stated that interventions had been implemented for this resident but acknowledged they were not updated in the care plan or medical record.

Removal Plan

• Define direct care staff as any trained individual who demonstrates competency per the facility aide competency checklist (including NA enrolled in CNA class employed, CNA, LVN, RN) for providing direct care/ADL assistance.
• Ensure at least two direct care staff on the floor at all times in addition to one LVN/RN charge nurse.
• Ensure a total of one LVN/RN and two direct care staff are in the building at all times if there are any mechanical lift residents.
• Assess staffing requirements based on census and resident needs.
• Maintain two direct care staff whenever the facility has any residents who use a mechanical lift or are a two-person transfer.
• Ensure DON/ADON verify all agency or temporary direct care staff have documented training prior to working a shift.
• Obtain access to the current temporary agency portal to check staff credentials.
• Require the sister facility to send CNA credentials prior to staff working a shift.
• For Resident #1, assess immediately upon discovery, send to hospital, follow discharge orders, notify physician/ADON/administrator/responsible party, initiate neuro checks/monitoring, remove NA-A from resident care pending investigation, and terminate NA-A.
• For Resident #5, assess and send to hospital, place reminder posters to use call light, educate resident on call light use, and work with hospice and follow hospice physician orders.
• For Resident #3, assess, notify hospice/doctor/family/administrator, transfer to hospital for evaluation, and continue monitoring for post-fall outcomes (pain, emotional distress, injury).
• Complete a 100% audit of all residents requiring mechanical lift transfers and display the list at the nurses station.
• Notify all staff of the mechanical lift resident list and include it in shift report and in the shower sheet book for aides.
• Send a text message to all direct care staff about the locations of the mechanical lift list.
• Have the ADON review the mechanical lift transfer list during shift report.
• Continue monitoring Residents #3 and #5 related to incidents and staffing comparison.
• Educate Residents #3 and #5 on call light usage on the same day as their respective falls.
• Educate staff on call light response expectations via informational handout at the nurses station with signature confirmation prior to starting first shift.
• Provide call light education at an in-service with an in-service signature sheet.
• Provide nursing staff education about call light usage and falls (DON via phone calls) and track completion; prevent staff from starting next shift until educated.
• Require all direct care nursing staff to take a quiz prior to working as direct care staff; grade prior to shift; re-educate and retest failures; remove from care if they fail the subsequent quiz.
• Re-educate all RNs/LVNs/CNAs/NAs on mechanical lift policy including two-staff requirement via protocol handout with staff signatures.
• Conduct follow-up in-service with return demonstration of mechanical lift use (COTA).
• Add proper mechanical lift use to new hire packets and competency checklists for direct care staff.
• Provide agency and sister-facility direct care staff an educational handout prior to starting shift (abuse/neglect, call light usage, mechanical lift transfer, falls) directed by charge nurse; verify competency via verbal return and staff signature.
• Re-educate staff on falls and post-fall procedures with documented signatures prior to start of first shift.
• Train new direct care staff on call light expectations during on-the-floor training before providing resident care; verify competency via verbal return and orientation sheet initials.
• Conduct an audit of in-services (mechanical lift use, incident reporting, abuse/neglect, falls, call lights) to ensure all staff trained; restrict work until training completed with verbal return; complete audits and report to IDT/QAPI.
• Complete competency validations for mechanical lift use for 100% of direct care staff (COTA/ADON) with signature validation.
• Conduct regular random observations of lift transfers by charge nurses and DON/designee; document in a log; suspend/remove staff from care until correct return demonstration if noncompliance occurs.
• Post signage above mechanical lift resident beds to remind staff which residents require mechanical lift use.
• Reinforce mechanical lift policy with clear disciplinary consequences for non-compliance; require staff to sign in-service sheet acknowledging review prior to working first shift.
• Have charge nurse/designee monitor transfers on each shift for compliance; track checks in a log at the nurses station; review by ADON in QAPI.
• Monitor a mechanical lift transfer once per shift with charge nurse initials; if noncompliance noted, immediately re-educate and remove staff from duty until proper return demonstration completed.
• If non-compliance is noted during monitoring, terminate staff who performed mechanical lift improperly and assess the resident for pain or injury.
• Report monitoring results at monthly QAPI.