BLOOMING PRAIRIE, MN - Federal inspectors found serious safety violations at Prairie Manor Care Center in July 2024, including unsafe mechanical lift practices that contributed to resident falls and inadequate management of behavioral symptoms in residents with trauma histories.
Mechanical Lift Safety Failures Lead to Multiple Falls
The most concerning violation involved unsafe mechanical lift equipment that resulted in two falls for a 187-pound resident with severe cognitive impairment. The resident, who required total assistance with daily activities, experienced falls from mechanical lifts on April 14 and June 1, 2024.
During the April incident, nursing assistant NA-D reported that the resident "got ahold of the leg straps and started viciously shaking them" while elevated in the lift. One of the leg straps came loose from its hook, causing the resident to fall. The June incident involved the resident sliding out of the mechanical lift sling and being lowered to the floor.
Investigation revealed the facility was using incompatible equipment - specifically Volaro brand mechanical lifts with Tollos brand slings. When contacted by inspectors, representatives from both companies confirmed they had not tested their products for compatibility with each other.
The Tollos Clinical Educator stated the company "had not tested their slings to be used with the Volaro mechanical lifts" and emphasized that proper training would be essential for safe use of any equipment combination. A Volaro representative was more direct, stating the company "does not recommend, as a manufacturer, the use of other branded slings with their lifts" due to safety concerns about gaps that could allow residents to slip out.
The facility's Director of Nursing acknowledged the equipment mismatch but revealed that staff had been making compatibility decisions through "visual inspection" rather than consulting with manufacturers or receiving proper training. The Assistant Director of Nursing admitted they "had not had the mechanical lift or sling companies out to the facility to do education with the staff."
This practice affected multiple residents, as five others in the facility used similar equipment combinations for transfers. The resident who fell had lost 32 pounds over six months, representing 15% of her body weight, yet the facility had not reassessed her equipment needs based on this significant weight change.
Industry Standards for Mechanical Lift Safety
Mechanical lifts are essential safety devices in nursing homes, designed to prevent injuries to both residents and staff during transfers. However, they must be properly matched and maintained to function safely. Manufacturers design slings specifically for their lift systems, with precise measurements and attachment points that ensure proper weight distribution and secure positioning.
When incompatible equipment is used, several risks emerge. Slings may not properly cradle the resident's body, creating gaps where the resident can slip through or fall out. Attachment points may not align correctly, leading to uneven weight distribution or mechanical failure. The resident in this case had a history of aggressive behaviors during transfers, making proper equipment fit even more critical for safety.
Weight loss significantly affects lift safety requirements. As residents lose weight, slings that once fit properly may become too large, creating loose areas where residents can slide or fall through. Standard protocols require reassessment of mechanical lift equipment when residents experience significant weight changes, typically defined as 5% or more of body weight.
Behavioral Care Management Deficiencies
The facility also failed to adequately address behavioral symptoms in a resident with a documented history of physical and emotional abuse. The same resident who experienced the mechanical lift falls displayed daily aggressive behaviors during personal care activities, including hitting, kicking, yelling, and threatening staff.
The resident's care plan identified her history of abuse by her father and husband, noting she would call out phrases like "You're hurting me" and "You're going to drop me" during care activities. Despite this trauma history and its clear connection to her behavioral responses, the facility had not updated her care plan interventions since admission.
Progress notes documented persistent aggressive behaviors throughout May and June 2024, with entries stating the resident was "still very combative towards staff during cares" and would "scream out at staff during cares, swing out and hit at them, kick, refuse cares." The behaviors consistently occurred during personal care activities, suggesting triggers related to her trauma history.
The facility's response focused primarily on medication management rather than trauma-informed care approaches. The resident received Seroquel, an antipsychotic medication, which was increased from 50mg daily to 50mg twice daily. However, staff received no specific training on trauma-informed care techniques or evidence-based behavioral interventions.
During the inspection, a nursing assistant stated she "would be more understanding if she knew a resident had a history of abuse" but admitted she had only heard rumors about the resident's background and "nothing that she was certain of." This indicated poor communication of critical care information between the interdisciplinary team and direct care staff.
Trauma-Informed Care Standards
Modern long-term care recognizes that many residents have experienced trauma, with studies showing up to 90% of nursing home residents have trauma histories. Trauma-informed care approaches focus on understanding how past experiences affect current behaviors and designing interventions that promote safety and trust rather than triggering traumatic memories.
Effective trauma-informed care requires comprehensive assessment of trauma history, identification of specific triggers, and development of individualized interventions. Staff need training to recognize trauma responses and implement calming techniques such as explaining procedures before beginning, maintaining consistent caregivers, and providing choices whenever possible.
Behavioral symptoms in dementia often have underlying causes including pain, fear, confusion, or trauma responses. Rather than relying primarily on medications, evidence-based approaches emphasize environmental modifications, communication techniques, and person-centered care strategies that address the root causes of distress.
Food Safety Violation
Inspectors also found a food safety violation when they discovered a cardboard box of oranges stored on the walk-in refrigerator floor, violating the facility's own policy requiring all food items to be stored at least six inches off the floor to prevent contamination.
The dietary director acknowledged the error, explaining that the oranges had been delivered on Friday but were not properly stored on shelving. Kitchen staff confirmed this violated contamination prevention protocols and could potentially affect all residents who consume food from the main kitchen.
Additional Issues Identified
The inspection revealed other operational concerns beyond the major violations. Documentation practices were inadequate, with nursing assistants reporting that behavioral tracking was limited to checkbox formats that restricted detailed reporting of interventions and their effectiveness.
Staff education gaps were evident across multiple areas, from mechanical lift safety to trauma-informed care. The facility lacked systematic processes for ensuring staff received comprehensive training on specialized equipment and evidence-based care approaches for complex behavioral situations.
Assessment and reassessment procedures needed improvement, particularly for residents with changing conditions or complex needs. The facility's quarterly review processes did not adequately address the need for ongoing evaluation of equipment appropriateness and intervention effectiveness.
The violations identified at Prairie Manor Care Center highlight critical safety and care quality issues that can significantly impact resident well-being. Mechanical lift safety requires strict adherence to manufacturer guidelines and proper staff training, while behavioral care for trauma survivors demands specialized knowledge and person-centered approaches that go beyond medication management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Prairie Manor Care Center from 2024-07-02 including all violations, facility responses, and corrective action plans.
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