F0689

D

Unsafe Mechanical Lift Use and Failure to Use Gait Belt During Resident Transfers

Buffalo, Missouri Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision during transfers, specifically in the use of a sit‑to‑stand mechanical lift and a gait belt. Facility policy on patient/resident handling, revised April 2025, states that safe procedures for providing care are a high priority, that handling incidents are to be analyzed for trends with appropriate follow‑up, and that employees are encouraged to report hazards and make safety suggestions. Despite this, staff actions during two separate transfer situations did not align with safe handling practices described by facility leadership and other staff.

In the first incident, a cognitively intact resident with a history of right ankle dislocation, generalized weakness, dependence on staff for transfers and ADLs, pain related to a previous fracture, and risk for falls reported that a CNA became frustrated while using a sit‑to‑stand lift during a bathroom transfer. The resident stated that the lift was hard to turn and that the CNA raised and lowered the lift, letting it hit the floor while the resident hung by the arms and swayed, causing upper chest soreness and fear. The resident reported having to yell at the CNA to calm down. Interviews with the CNA confirmed that two wheels on the lift locked up when attempting to roll the resident out of the bathroom, that the lift was stuck, and that the resident began swinging in the lift, causing concern the resident might fall. Other staff, including another CNA and nursing staff, reported that the floor in the resident’s room and bathroom was “horrible,” that the lift frequently got stuck on a notch or damaged area of the floor, and that the resident had reported being jostled and scared when the CNA shook the lift to get it unstuck.

The Maintenance Supervisor reported that a new floor had been installed in the resident’s room about a year earlier and that staff placed a sit‑to‑stand lift on it before the 24‑hour curing period, causing the floor to sink. He stated he had not received a work order or complaint about the lift wheels locking up, and that staff had previously indicated the lift was usable and were transporting residents across the bathroom floor. The DON and Administrator both stated that staff were expected to report issues with floors and equipment, including lift wheels locking up, and the DON acknowledged that rocking a lift back and forth to free it from a floor notch created safety issues. The CNA involved stated he was not aware whether maintenance had been informed of the lift getting stuck during the incident.

In the second incident, a resident with dementia, severely impaired cognitive skills, and total dependence on staff for mobility and ADLs was observed being transferred from bed to wheelchair by a CNA without the use of a gait belt, despite a gait belt hanging on the wall next to the bed. The CNA rolled the resident to a sitting position, sat the resident on the edge of the bed, then placed both hands around the resident’s back, stood the resident, pivoted, and seated the resident in a wheelchair. In interview, the CNA stated that he or she normally used a gait belt for all residents but believed this resident was care planned not to use one due to potential resistance, and therefore did not use a gait belt during the observed transfer, even though the resident was not combative or resistant at that time. Multiple staff, including other CNAs, OT staff, an LPN, the DON, and the Administrator, stated that staff should always use a gait belt during one‑person transfers when a lift is not used, that gait belts are the safest way to transfer, and that there was nothing in this resident’s care plan indicating a gait belt should not be used.

These events demonstrate that, in both cases, staff actions during transfers did not follow the safe handling expectations described by facility leadership and other staff, and that known environmental and equipment issues with the sit‑to‑stand lift and flooring were not effectively reported or addressed through the facility’s established hazard reporting processes.