Baptist Health Care Center Transfer Safety Harm ND
BISMARCK, ND - Baptist Health Care Center implemented immediate corrective measures and placed a certified nursing assistant on administrative leave after a transfer safety incident that resulted in a resident being sent to the emergency room in December 2024.
Transfer Safety Breach Leads to Emergency Room Visit
The incident at Baptist Health Care Center involved improper transfer techniques that violated federal safety standards for nursing home residents. According to the inspection report, a certified nursing assistant failed to follow proper gait belt procedures and transfer protocols when moving a resident, resulting in an incident serious enough to require emergency medical attention.
The facility's inspection documents reveal that the violation was classified as causing "actual harm" to residents, indicating that the safety breach had real consequences for patient wellbeing. The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility.
Medical Significance of Proper Transfer Techniques
Safe patient transfers are fundamental to nursing home care, particularly for elderly residents who may have compromised mobility, balance issues, or fragile bone structures. Gait belts are essential safety devices designed to provide caregivers with a secure grip when assisting residents with movement, reducing the risk of falls and injuries during transfers.
When transfer protocols are not followed correctly, residents face significant risks including falls, fractures, bruising, and potential head injuries. Elderly residents are particularly vulnerable due to factors such as decreased bone density, medication effects that may impact balance, and underlying medical conditions that affect stability and coordination.
The failure to use proper transfer techniques can result in serious injuries that may require hospitalization, extended recovery periods, and in some cases, permanent disability. For nursing home residents, even minor falls can have major health consequences and significantly impact their quality of life.
Facility Response and Corrective Actions
Baptist Health Care Center took immediate action following the incident, implementing several corrective measures to address the safety violation. The facility placed the involved certified nursing assistant on administrative leave pending further investigation and mandatory education.
The nursing home conducted comprehensive staff education, providing immediate training to all staff members working in the affected area about proper gait belt use and transfer procedures. Additionally, the facility implemented facility-wide education through their notification system, ensuring all direct care staff received updated training on transfer safety protocols and the importance of following individual resident care plans.
The facility also established new competency requirements, mandating that all direct care staff complete skill assessments related to gait belt use and proper transfer techniques for wheelchair transfers. This ensures that staff members demonstrate proficiency in safe transfer methods before providing direct patient care.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
BAPTIST HEALTH & REHAB in BISMARCK, ND was cited for violations during a health inspection on January 2, 2025.
The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.