Health inspection·November 13, 2025

Regulation Violation: §483.25(d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible: and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. §72523 - Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. Findings: On October 9, 2025, an unannounced visit was conducted at the facility to investigate a facility reported incident regarding Patient 1’s fall with injury while using the mechanical lift during transfer. On October 2, 2025, Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) did not ensure the attachment holding the bar and scale of the Hoyer lift (a mechanical device used to transfer people from one surface to another) was properly secured prior to Patient 1’s transfer. During the lifting, both LVN 1 and CNA 1 witnessed, as Patient 1 was being moved away from the bed, the attachment holding the bar and scale suddenly disconnected and Patient 1 fell on the floor. The facility failed to: a. Follow its Policy and Procedure (P&P) for safe patient handling and mobility. b. Follow manufacturer’s instruction guides to correctly and securely apply the attaching "C" clasp (used to fasten or hold objects together) on the scale portion of the Hoyer lift from the "C" clasp of the lifting strap during Patient 1’s transfer. These failures resulted in Patient 1’s falling, sustaining a laceration (a deep cut or tear in the skin) on the back of her head. Patient 1 received sutures to the back of her head and was required to be transferred to the general acute care hospital (GACH). Patient 1 was subsequently admitted to the intensive care unit (ICU) for a higher level of care. Findings: A review of Patient 1’s face sheet (contains demographic and medical information), indicated, Patient 1 was admitted to the facility on July 30, 2025, with diagnoses including anemia (insufficient red blood cells), chronic respiratory failure (when lungs are too weak to keep oxygen in and carbon dioxide out of the body for a long time), and cerebrovascular accident (CVA – when blood cannot get to a part of the brain and causes it to die from lack of oxygen). A review of Patient 1’s clinical record, “Physical Therapy Progress Summary,” dated August 29, 2025, indicated, Patient 1 was “dependent, total assistance. Impaired RLE (right lower extremity), impaired LLE (left lower extremity). Impaired attention and concentration, impaired orientation, impaired memory/learning…" A review of Patient 1’s clinical record, “Physician Note,” dated October 2, 2025, indicated, Patient 1 “…presents from the NCU [neuro care unit] after a fall. The patient developed a laceration on the back of her head. The patient was admitted to the hospital for a head CT [computed tomography – x-ray that takes detailed pictures of brain and skull]. The head CT was negative for intracranial [inside skull] hemorrhage [bleeding]. The patient had a 4 cm [centimeter—unit of measurement] laceration on the back of her head. Laceration sutured in the ICU. The patient will be transferred back to the floor…” A review of Patient 1’s clinical record, “Change of Condition” (details significant deviations from a patient’s baseline status, including physical, cognitive, behavioral, or functional changes), dated October 2, 2025, indicated, “Upon arrival in room found patient laying on ground with head on side of Hoyer lift and ventilator's (machine that assists in breathing when lungs cannot on their own) still connected to patient and left-hand mitten in place. Full body assessment done and noted laceration to back of head around 2 inches in length small amount of blood and pressure applied to stop bleeding…” A review of Patient 1’s clinical record, “RRT [Rapid Response Team—a group of health care profession who are called to bedside to assist in a sudden critical intervention] Activation and Response – Text,” dated October 2, 2025, indicated, “…Primary Call Reason: Other: Fall… RRT called had a fall from Hoyer lift, Per NCU staff patient was lifted above the level of the bed when she [Patient 1] fell from the Hoyer lift…Patient taken to CT then to ICU bed 10…Interventions: Other: Cleansed wound on head…" and “Outcome: Transferred to ICU.” During an interview on October 9, 2025, at 11:42 AM, with the Unit Manager (UM), the UM stated, Licensed Vocational Nurse (LVN 1) and Certified Nursing Assistant (CNA 1) used the Hoyer lift to weigh Patient 1. A sling was used and in the process of lifting, the attachment holding the sling and scale became disengaged and Patient 1 fell to the floor. During a concurrent observation and interview on October 9, 2025, at 11:50 AM, with the UM and Maintenance Staff (MS 1), in the maintenance room, both acknowledged the lift equipment present in the room was the lift equipment used to lift Patient 1. MS 1 demonstrated the attachment hook that would hold the scale and bar. The scale and bar had interlocking hooks that go on top of each other and had a red safety latch to ensure them from disengaging. MS 1 stated, “It would take a lot to actually get the attachment to disconnect all of a sudden. You would need to hold down the safety latch to get the hook out or have it sway enough where the hook is angled to where it can disconnect.” MS 1 further stated, “When we took it [the lift] out of the floor and assessed it, we didn’t [did not] see any physical problems, or anything fault about it. There’s no physical wear or anything.” During a concurrent interview and record review on October 9, 2025, at 12:03 PM, with UM, the facility’s document titled, “Clinical Engineering Request: 696164” (Work Order), dated October 2, 2025, was reviewed. The Work Order indicated biomed inspection was completed for [name of lift equipment] scale #132309953, confirming no mechanical defect. The UM stated, “based on the work order, there was no issue with the machine at the time of the fall.” A review of the facility's document, "Unusual Occurrence - Resident Fall with Laceration," dated October 7, 2025, indicated, "...the investigation concluded that the primary cause of the incident was the separation of the attaching "C" clasp on the scale portion of the hoyer lift from the "C" clasp of the lifting strap. This separation resulted in [Patient 1] dropping from the lift. She [Patient 1] landed on the floor where her head made contact with the leg of the lift, causing the laceration...evaluation found no problems, defects, or broken parts that might have contributed to the "C" clasp separating from each other...immediate education of proper hoyer lift usage was provided to the LVN and CNA..." During a phone interview on October 9, 2025, at 1:57 PM, with CNA 1, CNA 1 stated, the attachment holding the bar and scale was secured and CNA 1 checked before lifting Patient 1 out of bed. CNA 1 further stated, once Patient 1 started to lift, CNA 1 suggested to bring Patient 1 away from the bed as Patient 1’s body was still slightly touching the bed. CNA 1 added, as Patient 1 was being moved away from the bed, the attachment holding the bar and scale suddenly disconnected and Patient 1 fell to the floor. During a phone interview on October 9, 2025, at 3:26 PM, with LVN 1, LVN 1 stated, LVN 1 was standing on the right-hand side of Patient 1’s bed and CNA 1 was on the left. LVN 1 further stated, Patient 1’s feet were dangling on the bed after being lifted by the Hoyer lift, so CNA 1 said to move Patient 1 away from the bed to get an accurate weight reading. CNA 1 started moving the Hoyer lift away from the bed as soon as Patient 1 was not hovering over the bed, the attachment holding the scale and bar disconnected. Patient 1 fell and hit Patient 1’s head. Additionally, a Registered Nurse (RN) came into Patient 1’s room to assess wounds and found a bleeding laceration on the back of Patient 1’s head. LVN 1 confirmed LVN 1 was unsure about the safety and secureness of the attachment. LVN 1 further stated, LVN 1 observed CNA 1 verify the attachment. During an observation on October 10, 2025, at 2:24 PM, in Patient 1’s room, Patient 1 was observed to be resting in bed, positioned by pillows on the right side. Mitten was observed on left hand. Laceration on head did not have sutures and appeared dry. During a review of the "[name brand of lift] Instruction Guide,” revised May 31, 2012, the instruction guide indicated, “…Safety Instructions:…Before lifting always make certain that:…the lifting accessories is selected appropriately in terms of type, size, material and design with regard to the patient's needs; lifting accessories are not damaged; the lifting accessory is correctly applied to the lifting equipment; the lifting accessory is correctly and securely applied to the patient, so that no personal injury can occur…" During a concurrent interview and record review on October 10, 2025, at 3:00 PM, with the Clinical Director (CD), the facility’s policy and procedure (P&P) titled, “Safe Patient Handling and Mobility Program, “revised July 2023, was reviewed. The P&P stated, “…Supporting a culture of safety and accountability by setting expectations for the utilization of safe patient handling and mobility techniques and technology by staff…" The CD stated, the facility did not follow the P&P. During a phone interview on October 16, 2025, at 1:12 PM, with the Administrator (Admin), the Admin stated that there were no issues with the Hoyer lift machine, and it was in working condition prior to Patient 1's fall incident. The Admin further stated, the nursing staff were at fault and should have been more careful regarding proper Hoyer lift usage and safety to prevent similar errors in the future. During a phone interview on October 17, 2025, at 12:57 PM, with MS 2, MS 2 stated, the Hoyer lift was last inspected in October 2024, it was scheduled for annually (once a year) inspection, so it would be due for maintenance again by the end of October 2025. MS 2 further stated that the separation of the attaching "C" clasp on the scale portion of the Hoyer lift from the "C" clasp of the lifting strap was probably caused by the insecure attachment of the “C” clasp between the scale and lifting strap and not due to any fault to the machine. Conclusion: In violation of the above cited standards, the facility failed to: a. Follow its Policy and Procedure (P&P) for safe patient handling and mobility. b. Follow manufacturer’s instruction guides to correctly and securely apply the attaching "C" clasp on the scale portion of the Hoyer lift from the "C" clasp of the lifting strap during Patient 1’s transfer. These failures resulted in Patient 1’s falling, sustaining a laceration on the back of her head. Patient 1 received sutures to the back of her head and was required to be transferred to the general acute care hospital (GACH). Patient 1 was subsequently admitted to the intensive care unit (ICU) for a higher level of care. These violations, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of patients or residents.