SOAP LAKE, WA - A resident at McKay Healthcare & Rehab Center fell from a mechanical lift and required hospitalization after agency nursing assistants failed to follow basic safety protocols during a routine transfer.
Resident Falls from Sit-to-Stand Lift
On December 31, 2024, a resident experienced a fall from a sit-to-stand lift during a morning transfer from bed to wheelchair. The incident occurred when two agency nursing assistants attempted to move the resident using the mechanical lift device, which requires residents to bear some of their own weight during transfers.
Federal inspectors found that Staff C, who had been working at the facility for less than a month, was left alone in the room with the resident positioned in the standing lift. The resident then "leaned forward and slowly slid off the foot plate of the sit-to-stand," according to Staff C's account to investigators. The staff member reported being "in shock, confused, and didn't know what to do" and ultimately placed the resident on the floor.
Critical Safety Buckle Missing
The facility's own policy requires that when using a sit-to-stand lift, staff must secure the resident by buckling the lift sling around the resident's waist prior to transfer. However, Staff D observed that the resident "did not have the buckle on, just the sling around [their] back" when they returned to find the resident on the floor.
Staff D explained to investigators that "the buckle is for safety so they can't slip or fall," highlighting the critical nature of this safety feature that was not properly utilized during the transfer.
Lack of Training and Competency Verification
The inspection revealed systemic failures in ensuring agency staff competency. Staff C admitted to having no knowledge of the facility's mechanical lift policies, stating "No, not really. I don't know" when asked about transfer procedures. Their only prior exposure to mechanical lifts was a single encounter with a different type of lift at another facility.
When Staff C arrived at McKay Healthcare, they received only basic orientation consisting of resident information sheets and break schedules. No mechanical lift training was provided, despite the complex nature of these transfers and their potential for serious injury.
Agency Staff Oversight Failures
The facility employed 21 agency nursing assistants but failed to verify competencies for multiple staff members. Staff G, the Staffing Coordinator, confirmed that Staff C's proficiency skills checklist was not requested from the staffing agency until January 3, 2024 - three days after the fall and 15 days after the staff member began working.
Similarly, Staff D had worked 14 shifts at the facility since December 2024, but no documentation existed to establish their skills proficiency. Two additional agency staff members, Staff E and Staff F, who had been working at the facility since April 2024, also lacked proper competency verification.
Medical Risks of Improper Transfers
Mechanical lift transfers are critical safety procedures in healthcare facilities. Sit-to-stand lifts require precise positioning and security measures because they involve partial resident mobility and weight-bearing. Without proper buckle securement, residents can slip, slide, or fall, potentially resulting in hip fractures, head injuries, or other serious trauma.
The resident's care plan specifically indicated they could not pull themselves to a standing position with one-person assistance and required a two-person assist with the sit-to-stand lift. This protocol exists because the resident's physical limitations create additional fall risk during transfers.
Industry Standards for Staff Competency
Healthcare facilities are required to ensure all staff, including temporary and agency personnel, demonstrate competency in essential care procedures before providing resident care. This includes hands-on demonstration of mechanical lift operations, understanding of safety protocols, and familiarity with individual resident needs.
The Administrator acknowledged that agency staff proficiency "should be obtained and confirmed prior to their coming to work or at the time of their shift. Absolutely, like ASAP [as soon as possible]."
Regulatory Response
The Centers for Medicare & Medicaid Services cited McKay Healthcare & Rehab Center under federal regulation F726 for failing to ensure nursing assistants have appropriate competencies to maximize resident well-being. The violation was classified as having potential for actual harm affecting some residents.
The Director of Nursing confirmed that the facility "didn't do our competencies or orientation" with the agency staff involved in the incident, representing a clear departure from established safety standards.
This incident highlights the critical importance of proper staff training and competency verification in preventing preventable injuries during routine care procedures at nursing facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mckay Healthcare & Rehab Ctr from 2025-01-07 including all violations, facility responses, and corrective action plans.
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