F0689

J

Unsafe Transfers, Damaged Equipment, and Policy Noncompliance Lead to Resident Injuries

Charlotte, North Carolina Survey Completed on 03-02-2026

Penalty

Fine: $26,685

Summary

The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for multiple residents, including a dependent resident receiving anticoagulant therapy. One resident with diabetes mellitus, right tibia fracture, hypertension, muscle weakness, osteoporosis, history of DVT, and physical debility required two-person assistance with transfers and was on Eliquis, a medication with manufacturer guidance warning of serious bleeding risks. A PT evaluation documented severely decreased bilateral lower extremity range of motion, contractures, and an inability to tolerate upright positioning without both legs elevated on pillows and leg rests. Despite these needs, on the day of the incident a nurse aide performed a one-person mechanical lift transfer from bed to wheelchair and then pulled the resident’s wheelchair backward alongside the bed, striking the resident’s lower left leg against a damaged bed footboard with missing laminate and exposed pressboard.

Following the impact with the damaged footboard, the resident immediately cried out in pain, reported severe pain at a level of 10/10, and had active bleeding from a one-inch laceration on the lower left leg. The aide initially attempted to control the bleeding with paper towels and then a bath towel, which became saturated, before calling a nurse. The nurse assessed a one-inch slit on the left lower leg, noted increased bleeding related to anticoagulant therapy, applied pressure for approximately five minutes, and then applied a pressure dressing. Documentation indicated the resident’s anticoagulant was held and that the wound nurse and NP were notified. EMS records later described the nurse reporting difficulty controlling bleeding at the facility and that the resident continued to complain of severe pain, with elevated blood pressure and heart rate during EMS assessment. Hospital records documented a large superficial soft tissue hematoma of the left lower extremity, a significant drop in hemoglobin consistent with acute blood loss anemia requiring transfusion, and subsequent skin necrosis over the hematoma that required operative evacuation, surgical debridement, and wound VAC placement.

The deficiency also includes the facility’s failure to ensure environmental safety and adherence to policies for other residents. One cognitively intact resident with rheumatoid arthritis, generalized muscle weakness, diabetes mellitus, and a care plan identifying fall risk due to impaired mobility, lower extremity weakness, psychoactive medication use, and visual impairment reported falling in the shower after using a loose grab bar. During a therapy session in the shower room, the resident told the OT that the grab bar was loose, but the OT did not respond and instructed the resident to rinse off. When the resident stood and pulled on the grab bar, it moved significantly, causing her to fall back onto the shower chair and then slide to the floor on her buttocks. The resident could not get up due to chronic knee and leg weakness and the wet, slippery floor, and therapy staff had to use a mechanical lift to transfer her to her wheelchair before she was later evaluated at the hospital.

Additional deficiencies were identified related to supervision and environmental safety for residents who smoked. The facility failed to follow its smoking policy by allowing residents to keep smoking materials on their person and in their rooms instead of having them locked at the nurses’ station. This practice was identified for multiple residents reviewed for supervision to prevent accidents. The combination of unsafe transfer practices, use of damaged furniture that created an accident hazard, failure to respond to a reported loose grab bar in the shower, and noncompliance with the smoking materials policy led surveyors to determine that the facility did not ensure a safe environment free from accident hazards or provide adequate supervision to prevent accidents for several residents.