F0726

K

Untrained Aides and Improper Mechanical Lift Use Resulting in Resident Fracture

Merkel, Texas Survey Completed on 02-16-2026

Penalty

Fine: $204,535

Summary

The deficiency involves the facility’s failure to ensure that nurse aides demonstrated competency in skills and techniques necessary to meet residents’ needs, particularly in the use of mechanical lifts and performance of transfers. The facility’s own Nurse Aide Orientation/Evaluation checklist, undated, stated that NAs could not perform tasks such as helping patients into a chair from bed or into a wheelchair by themselves. Despite this, multiple NAs were working full time without documented certification or evidence of mechanical lift training. Personnel files for several NAs (including NA-A, NA-C, NA-F, NA-G, NA-H, NA-J, NA-L, and NA-P) lacked documentation of mechanical lift training, and some had no evidence of any orientation or evaluation checklist at all.

One resident, identified as Resident #1, was directly affected when NA-A transferred the resident using a mechanical lift without the assistance of another CNA or nurse, contrary to facility policy and the stated requirement that at least two staff are needed for mechanical lift transfers. This incident resulted in Resident #1 sustaining a distal femur fracture. The facility’s policy titled “Lifting Machine, Using a Mechanical Lift,” revised July 2017, specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift, and the nurse aide job description required that aides be enrolled in a state-approved competency training program and perform only services for which they had demonstrated competence.

Interviews with staff further demonstrated the lack of competency and training oversight. NA-F and NA-G each stated they were not certified and had not been trained regarding two-person mechanical lift transfers, although they provided full resident care without restrictions. The AIT confirmed that the NA checklist defined what NAs were allowed to do and that transfers were not allowed to be done alone by NAs; she also verified that two-person mechanical lift transfers were not on the NA checklist and that she could not locate NA-A’s checklist or any training records. The ADON stated that NAs could not perform any transfers without a CNA or nurse and that even two NAs together could not perform these activities, indicating that nurses were supposed to supervise NAs to ensure they did not perform tasks for which they were not trained. The MD reported he was not aware that the facility had been using so many uncertified aides and stated his expectation that staff follow facility policy and work within their scope of practice. These findings led surveyors to identify an Immediate Jeopardy situation related to the lack of competent nursing staff and improper use of mechanical lifts.

Removal Plan

• Ensure there are two direct care staff on the floor at all times in addition to one LVN/RN charge nurse when there are any mechanical lift residents.
• Assess staffing requirements based on census and resident needs, ensuring two direct care staff if the facility has any residents that use a mechanical lift or are a two-person transfer.
• Ensure DON and ADON verify that all agency or temporary direct care staff have documented training prior to working a shift.
• Provide immediate assessment and treatment for Resident #1 following the mechanical lift incident, including hospital transfer and following discharge orders.
• Conduct an immediate review of staffing credentials for all staff to identify uncertified aides.
• Move all uncertified staff to hospitality aide positions and utilize temporary staffing agency to meet certified aide requirements.
• Remove any direct care staff not meeting CNA requirements from assignments requiring certification.
• If aides are not certified, move them to hospitality aide positions or relieve them from duty and do not count them toward the two direct care staff count.
• Redefine aide requirements with clear definitions and assign titles accordingly to all aides.
• Ensure only certified nurse aides are assigned to CNA-required roles.
• Assign the AIT responsibility for scheduling CNAs for each shift and utilize temporary staffing agencies and sister facility aides to meet certified aide requirements.
• Verify active CNA certification prior to scheduling.
• Educate all staff on call light usage.
• Perform license verification checks for all direct care staff upon hire and thereafter, with AIT review for accuracy and completion.
• Train all direct care staff on falls and call light usage via phone calls with return instruction to ensure retention of information.
• Prevent staff who do not complete phone training/return instruction from returning to work their shift until retrained on falls and call lights.
• Have Administrator/DON review staffing roster to ensure compliance and use staffing agencies/sister facility aides if non-compliance is discovered.
• Provide all agency and sister facility direct care staff an educational handout prior to starting their first shift on the floor, directed by the charge nurse.
• Require agency and sister facility staff to sign a check-in sheet each shift confirming review of educational material.
• Verify competency through verbal return demonstration of information and staff signature.
• Review monitoring findings in QAPI.