F0689

D

Failure to Use Required Two-Person Assist for Mechanical Lift Transfer

Black River Falls, Wisconsin Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible by not following its own policy requiring two staff members for all mechanical lift transfers. The facility’s Body Mechanics - Transfer Training policy, reviewed in 11/2024, specifies that two CNAs, licensed nurses, or therapists are required for mechanical sit-to-stand and full-body lift use. The resident involved, R3, was admitted with dementia and had a BIMS score of 00, indicating cognition not intact. R3’s most recent MDS documented a need for substantial/maximal assistance with bed mobility and dependent assistance with toileting hygiene, sit-to-stand, chair/bed transfers, and toilet transfers. R3’s care plan required use of a sit-to-stand lift for all transfers and documented toileting assistance of one.

During observation, the surveyor saw that R3 was transferred from the bathroom to a wheelchair using a sit-to-stand lift by one CNA (CNA D) without a second staff member present. CNA D confirmed she had been trained on safe transfer techniques and knew that two staff were required for lift equipment transfers, and she stated she was aware R3 needed two staff for use of the lift machine but proceeded alone because the nurse was busy and R3 needed to be transferred. Other staff interviewed, including another CNA and an RN, stated that the expectation was that two staff are required for all lift transfers, and review of R3’s care plan by staff confirmed that a sit-to-stand lift was required for transfers, which they understood to mean two staff assistance. Facility leadership also acknowledged that the expectation is for two staff to assist with resident transfers using lift equipment and that this was a concern given repeated staff education on resident safety with lift transfers.