F0689

G

Injury from Failure to Follow Mechanical Lift Transfer Care Plan

Burlington, Vermont Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and adherence to an individualized transfer care plan for a resident with significant bone fragility. The resident had diagnoses of Osteogenesis Imperfecta and Osteoporosis, conditions that make bones weak and easily fractured. The resident’s care plan specified that transfers were to be performed using a Hoyer lift with two staff members, in accordance with the facility’s Safe Resident Handling/Transfers policy, which requires staff to follow each resident’s individual plan of care. Despite these requirements, an LNA independently performed a manual transfer of the resident from a wheelchair to a bed, lifting the resident under the arms instead of using the mechanical lift and a second staff member.

During the transfer, the resident told the LNA to use the mechanical lift, but the LNA continued the manual transfer. After being placed in bed, the resident felt a pop and experienced discomfort, which was reported to the LNA. The resident later reported pain in the upper back and right shoulder area, and the LNA informed the LPN that the resident needed pain medication, initially stating the pain followed assistance with removing a sweater. Upon assessment, the LPN noted limited range of motion and grimacing with movement, and the resident reported that the LNA had lifted them into bed. The LNA confirmed to facility leadership that she had transferred the resident without the Hoyer lift and was aware of, but did not follow, the care plan. Hospital evaluation documented a fractured scapula, and both the Administrator and DON confirmed that the LNA failed to comply with the resident’s care plan and facility policy, resulting in the resident’s injury.