F0689

G

Improper Use of Sit-to-Stand Lift Causes Resident Leg Bruising

Decatur, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

A deficiency occurred when staff failed to follow the resident’s assessed transfer status and the facility’s Safe Lifting and Movements of Residents policy, resulting in improper use of a sit-to-stand lift and injury. The cognitively intact resident, who had lymphedema in both legs and was dependent on staff for chair, bed, and toilet transfers, was care planned to use a full mechanical lift for transfers to and from bed and a sit-to-stand lift only for toileting in the shower room. Despite this, CNAs used a sit-to-stand lift to transfer the resident into bed, positioning the resident too close to the metal bed frame, which led to the back of the resident’s right leg striking the frame. The resident subsequently developed a baseball-sized blue/purple bruise and hardening on the back of the right calf/knee area and reported new right leg pain that required pain medication.

During surveyor observation, CNAs were again seen using a sit-to-stand lift for toileting, with the resident bearing weight in a bent posture, knees not fully extended, and the chest strap left loose because the resident reportedly did not like it tightened. The resident grimaced, moaned, and complained of pain during these transfers and pointed out the bruise, stating that staff had banged her leg on the bed and that it hurt. Interviews and record review confirmed that some staff used a full mechanical lift and others used a sit-to-stand lift for bed transfers, and that at least one CNA had recently started working on the hallway and had been told the resident used a sit-to-stand lift, contrary to the care plan and posted instructions in the room. These actions and inconsistencies in following the documented transfer requirements led to the resident’s bruising and pain.