F0689

G

Improper One-Person Mechanical Lift Transfer Resulting in Leg Fractures

West Lafayette, Indiana Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was kept safe during a mechanical lift transfer, resulting in a right leg fracture. The resident had diagnoses including abnormalities of gait and mobility, lack of coordination, and dementia, and had a physician’s order requiring use of a mechanical lift for all transfers. The resident’s care plan documented impaired transfer ability and required a mechanical lift with a minimum of two staff members for all mechanical lift transfers.

On one evening, the resident was transferred for dinner using a mechanical lift by two CNAs, and no pain or problems were reported at that time. Later that evening, one CNA transferred the resident alone using the mechanical lift, contrary to the care plan, facility policy, and mechanical lift guidelines, all of which required at least two staff for safe use. An RN later observed the mechanical lift in the resident’s room with that CNA present and indicated the injury could have been caused during a mechanical transfer. Another nurse indicated the accident could have occurred during a mechanical lift transfer or if the resident’s leg hit the metal portion of the bed frame.

The following day, while the resident was being changed, staff noted bruising to the right shin, severe pain in the right hip, and an absent pedal pulse in the right foot. The resident was sent to the emergency room, where imaging showed a minimally displaced oblique fracture of the mid tibial diaphysis and a minimally displaced spiral fracture of the proximal fibular diaphysis. The facility’s investigation documented that the CNA admitted to performing the post-dinner mechanical lift transfer alone and reported no issues during the transfer, but the cause of the fracture was not definitively determined.