Baptist Health Care Center Lift Injury Violation - ND
BISMARCK, ND - Federal inspectors cited Baptist Health Care Center for safety violations after a resident was injured during a transfer using a mechanical lift when staff failed to follow proper safety protocols and equipment was improperly configured.
Mechanical Lift Accident Results in Resident Injuries
On January 4, 2025, a resident at Baptist Health Care Center experienced a serious fall when certified nursing assistants improperly used a mechanical lift during a routine transfer from a specialized wheelchair to bed. The incident, which occurred around 6:15 p.m., resulted in facial lacerations and a painful hematoma on the resident's back.
According to the facility's incident report, two CNAs were transferring the resident from a Broda wheelchair using a full-body lift when complications arose. "During the transfer, the residents sling became caught on part of the wheelchair," the report stated. When staff attempted to free the sling by moving the wheelchair, the lift became unbalanced, struck one of the CNAs in the head, and then made contact with the resident's face.
The mechanical lift subsequently tipped over on its side, causing the resident to fall approximately three feet to the floor while still secured in the sling. The impact caused a skin tear above the resident's right eye and on the bridge of his nose, requiring sutures. Medical staff also discovered a hematoma on the resident's lower back that was painful to touch.
The resident required emergency medical attention and was transported by ambulance to a local hospital for treatment. Nursing notes documented that the facial sutures were dissolvable, and the resident's wife was kept informed of his condition and treatment.
Critical Safety Protocol Failures
Federal regulations require nursing homes to ensure residents receive adequate supervision and proper use of assistive devices to prevent accidents. The facility's own policy for mechanical lift use mandated specific safety checks that were not properly followed during this incident.
The facility's floor-based, full-body sling lift policy required staff to perform multiple safety verifications before lifting any resident. These included ensuring slight tension on sling loops, double-checking that each loop was securely hooked, verifying the position and stability of all straps and equipment, and confirming the resident would not slide out or tip during the transfer.
Most critically, the policy required staff to lift the resident only about two inches off the surface initially to verify proper weight distribution and positioning before proceeding with the full transfer. This safety step appears to have been bypassed or improperly executed, as the resident was lifted to full height before the equipment malfunction occurred.
Mechanical lift transfers are considered high-risk procedures in long-term care settings because they involve suspending residents in the air using complex equipment. When protocols are not followed precisely, residents face significant injury risks including falls, equipment strikes, and pressure injuries from improper sling positioning.
Equipment Configuration Problems Contributed to Incident
Investigation revealed that the resident's specialized Broda wheelchair had been improperly configured, creating hazards that contributed to the accident. The wheelchair's arm rest handles had been installed upside down, creating protruding obstacles that could easily catch sling straps during transfers.
A facility purchasing employee discovered the configuration error two weeks after the incident, noting in an email: "I found the handles at the end of arm rest were placed upside down which could have been where the sling got caught." The employee corrected the handle positioning, but the improper setup had gone unnoticed despite regular use of the equipment.
This equipment configuration issue represented a systemic failure in the facility's safety oversight. Specialized wheelchairs like Broda chairs require proper setup and regular safety inspections to ensure they don't create transfer hazards. The handles should have been positioned to minimize obstruction during mechanical lift operations.
An occupational therapist had reviewed the Broda chair just one month before the incident but failed to identify the improper handle configuration. The December 9, 2024 assessment noted the resident's continued use of the specialized chair but made no mention of safety concerns or equipment positioning issues.
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 23, 2025.
The incident, which occurred around 6:15 p.m., resulted in facial lacerations and a painful hematoma on the resident's back.
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.