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.
Medical Risks of Mechanical Lift Accidents
Falls during mechanical lift transfers pose particularly serious health risks for nursing home residents, who often have multiple medical conditions that increase injury vulnerability. The three-foot fall experienced by this resident could have resulted in fractures, head injuries, or internal trauma, especially given the advanced age and frailty typical of long-term care populations.
Facial injuries like those sustained by the resident require careful monitoring for complications. Skin tears near the eyes can affect vision if swelling occurs, and facial wounds in elderly patients heal more slowly and are prone to infection. The hematoma on the resident's back indicated significant impact force and required ongoing assessment for underlying tissue damage.
The psychological impact of such incidents also cannot be overlooked. Residents who experience falls during care procedures often develop anxiety about future transfers, which can complicate their daily care routines and rehabilitation efforts.
Proper mechanical lift operation prevents these injuries by ensuring controlled, smooth transfers that keep residents secure throughout the process. When safety protocols are followed, mechanical lifts actually reduce injury risk compared to manual transfers, but only when used correctly by properly trained staff.
Industry Standards for Transfer Safety
Medicare and Medicaid regulations require nursing homes to maintain accident-free environments and provide adequate supervision during all care procedures. This includes ensuring staff are properly trained on mechanical lift operation and that all equipment is correctly maintained and configured.
Best practices in long-term care emphasize a culture of safety where staff are empowered to stop procedures if equipment appears problematic or if safety checks reveal concerns. The incident at Baptist Health Care Center suggests this safety culture may need strengthening, as staff proceeded with the transfer despite the sling becoming caught on the wheelchair.
Professional standards also require regular equipment inspections and immediate correction of any configuration issues that could pose safety risks. The upside-down handles on the Broda chair should have been identified and corrected during routine safety rounds or equipment checks.
Additional Issues Identified
The inspection also revealed deficiencies in the facility's abuse prevention training program. While these issues were considered past non-compliance since corrective actions had been implemented, they indicated broader concerns about staff education and oversight.
The facility had implemented corrective measures including mandatory staff education on abuse definitions and reporting requirements. All facility staff were required to complete this training within one week of assignment, and supervisors had to document completion through signed acknowledgment forms.
These educational requirements reflected federal expectations that nursing home staff maintain current knowledge of resident protection protocols and reporting obligations. Proper training helps staff recognize concerning situations and take appropriate action to protect resident safety and rights.
The combination of safety protocol failures and educational deficiencies identified during this inspection highlighted areas where Baptist Health Care Center needed to strengthen its quality assurance programs and staff oversight procedures to better protect resident safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Baptist Health Care Center from 2025-01-23 including all violations, facility responses, and corrective action plans.
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