MISSION HILLS, CA - A resident at Ararat Nursing Facility died from injuries sustained during a mechanical lift accident after a certified nursing assistant violated safety protocols by leaving the vulnerable resident unattended.
Fatal Mechanical Lift Incident
The June 1, 2024 incident involved a resident with severe cognitive impairment from Alzheimer's disease and dementia who was completely dependent on staff for all care activities. The resident had been at the facility since July 2021 and required mechanical lift assistance for all transfers due to their condition.
According to the federal inspection report, CNA 1 was preparing to weigh the resident using a mechanical lift when she left the resident unattended to seek assistance from another staff member. "I was almost at the door when I heard a loud sound. I turned my back, opened the curtain and I saw my resident on the floor on the legs of the lifting machine," CNA 1 stated in the inspection report.
The resident was found with blood around their head and was immediately transported to the hospital emergency department.
Severe Injuries and Death
Emergency department records documented extensive trauma from the fall. The resident sustained a V-shaped laceration across the forehead, lacerations to the area below the right eye, and discoloration around both eyes from trauma.
Medical imaging revealed the most serious injuries: a Type III odontoid fracture in the cervical spine and multiple facial bone fractures. The odontoid process is a critical part of the second cervical vertebra that allows the head to rotate. Type III fractures in this area are particularly dangerous as they can affect spinal stability and potentially compress the spinal cord.
The resident died in the emergency department the same afternoon from these injuries.
Multiple Safety Protocol Violations
The inspection revealed several critical safety failures that contributed to the fatal accident:
Two-Person Requirement Ignored: Facility policy and standard medical practice require two staff members when using mechanical lifts with dependent residents. "For use of a lift machine, it is always with two staff because it's dangerous if done by self," stated CNA 4 during the inspection interview.
The two-person protocol exists because one staff member must operate the lift mechanism while the other ensures the resident remains properly positioned in the sling and monitors for any complications during the transfer.
Missing Physician's Order: The resident was being transferred using a mechanical lift without a required physician's order, violating the facility's own policy that states "The resident will have a physician's order for the use of a mechanical lift."
Care Plan Violations: The resident had a fall risk score of 16, well above the high-risk threshold of 10. Their care plan specifically required floor mats beside the bed to cushion potential falls, but "There was no floor mat where the patient had landed," according to CNA 1's statement.
Industry Standards for Mechanical Lift Safety
Mechanical lift transfers require strict adherence to safety protocols due to the vulnerability of residents who depend on these devices. Standard practice dictates that cognitively impaired residents should never be left unattended during any part of the transfer process, as they cannot communicate distress or adjust their position if the sling shifts.
The sling component of mechanical lifts can move unexpectedly, and residents with cognitive impairment may not understand instructions to remain still. This is why facility staff acknowledged that "having only one staff cannot hold the lift machine and keep the resident steady on the sling all at the same time."
Immediate Jeopardy Determination
Federal inspectors assigned this violation the most serious level of harm: immediate jeopardy to resident health or safety. This determination indicates that the facility's practices created a situation where serious injury, harm, impairment, or death was likely to occur without immediate intervention.
"I would not have left the resident alone," stated RN 1 when asked what should have been done differently. "I would not leave the lift machine unattended because we always make sure the residents' environment needs to be free from hazards."
The mechanical lift became a hazard when left positioned near the bed with a cognitively impaired resident, as the metal legs of the device created a dangerous obstruction that caused fatal injuries when the resident fell.
This incident highlights the critical importance of following established safety protocols in nursing home care, particularly when working with residents who have cognitive impairments and depend entirely on staff for their safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ararat Nursing Facility from 2024-06-14 including all violations, facility responses, and corrective action plans.
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