OSSEO, MN - A nursing assistant at The Villa At Osseo has been suspended following a January 17, 2025 incident in which a resident sustained a fractured femur after being transferred without required mechanical lift equipment, captured on camera footage that revealed multiple care protocol violations over a four-minute period.
Transfer Protocol Violations Lead to Serious Injury
The incident involved a 211-pound resident with significant mobility limitations, including right-sided paralysis from a previous stroke, chronic pain syndrome, and a history of hip and ankle fractures. According to her care plan, the resident required assistance from one staff member using a mechanical standing lift for all transfers—a safety measure designed to protect both the resident and caregiving staff.
Video footage from the morning of January 17 shows nursing assistant NA-B attempting to transfer the resident from bed to wheelchair without the required equipment. The footage, reviewed by facility administrators and state surveyors, documented the resident lying across the bed with her legs hanging over the edge, her clothing disheveled, and her abdomen exposed. Rather than retrieving the mechanical lift as specified in the care plan, the assistant proceeded with a manual transfer approach.
During the attempted manual transfer, NA-B grabbed the resident by the back of her shorts without applying a transfer belt—another required safety device. As the assistant attempted to pivot the resident toward the wheelchair, the resident's right leg buckled under her weight, and she fell to the floor. The resident cried out in distress as her legs became trapped beneath her body during the fall.
Medical imaging later revealed the resident had sustained a peri-implant right supracondylar distal femur fracture—a break in the thigh bone just above the knee. On January 20, the resident underwent surgical intervention requiring open reduction internal fixation with plate and screw hardware to repair the fracture.
Medical Significance of Protocol Violations
The care protocols violated in this incident exist specifically to prevent the type of injury that occurred. Mechanical lift requirements are based on careful assessment of multiple factors including a resident's weight, level of paralysis, cognitive function, and fall risk.
This resident's medical history made manual transfers particularly hazardous. Her right-sided hemiplegia meant she had little to no ability to bear weight on or control her right leg. Her severe morbid obesity classification, combined with generalized muscle weakness, meant she could not compensate for loss of stability. Additionally, her diagnosis requiring anticoagulation medication—used to prevent blood clots—increased her bleeding risk from any trauma, making injury prevention even more critical.
Femur fractures in individuals with complex medical conditions carry serious risks beyond the immediate injury. Surgical repair requires general anesthesia, which presents elevated risks for patients with respiratory conditions. The prolonged immobility during recovery increases risks for pressure ulcers, blood clots, pneumonia, and muscle deconditioning. For residents with existing mobility limitations, a major fracture can permanently reduce functional independence.
The facility's own care plan acknowledged these vulnerabilities, documenting interventions directing staff to "encourage resident to avoid bumping herself" due to anticoagulation use. The care plan also identified the resident as a vulnerable adult requiring staff to provide care "in a gentle, unrushed, and thorough manner."
Pattern of Concerning Care Practices
The video footage revealed care quality concerns extending beyond the transfer technique failure. Over the four minutes and 14 seconds of recording, the footage documented the assistant handling the resident with what facility administrators characterized as "unnecessary roughness."
The resident made repeated vocalizations of pain, including crying out "OW" when her legs were forcibly moved and positioned. When the assistant swung the resident's right lower leg onto pillows at the end of the bed, the leg "flopped" onto its side with enough force that it visibly bounced. Medical records indicate this was the same leg that would later fracture.
Throughout the recording, the assistant used elevated tone and demanding language, telling the resident "You are not getting out" while shaking a pointed finger, and stating with frustration "Than what should I do...I can't let you sit" when the resident expressed inability to perform requested movements. The assistant made physical contact that could be heard on the recording, including swatting the resident's hip and abdominal areas.
The resident, who had moderate cognitive impairment and aphasia affecting her ability to communicate, attempted to gesture and point, but these communications went unacknowledged. She repeatedly made grunting sounds of exertion and distress as she struggled with positioning demands.
When interviewed after viewing the footage, facility administrators stated they were "definitely taken back" and confirmed the care provided did not meet standards. The Director of Nursing noted "You can clearly tell [the resident] was in pain throughout that" and stated the assistant's actions "did not change during the encounter, even after [the resident] made verbalizations of distress."
Staff Knowledge and Training Failures
Investigation revealed systemic failures in ensuring staff compliance with individualized care plans. When initially interviewed on January 17, NA-B stated she was unaware the resident required a mechanical standing lift for transfers, despite this being clearly documented in multiple locations including the comprehensive care plan, the nursing assistant-specific Care Guide, and the electronic medical record task system.
NA-B acknowledged during follow-up interviews that she "overall does not review the care guides, especially for [this resident], as she knows her so well." She stated she only reviewed care guides for new admissions or when working with unfamiliar residents on other units. She confirmed she did not carry the care guides with her during shifts, contrary to facility expectations.
When questioned about her approach, NA-B defended her actions as necessary due to the resident's size and her attempts to reduce the resident's pain during leg movements. She stated she did not use a transfer belt because she planned to have the resident remove her shirt while seated at the bedside, then apply the belt afterward—a sequence that left the resident without safety equipment during the most dangerous phase of the transfer.
Notably, NA-B continued working for three additional days following the incident before being sent home on January 20. The facility's investigation was not initiated until January 11, when the resident's husband provided camera footage to administrators, despite the incident occurring on January 17 and being documented in nursing notes that same day.
Regulatory Response and Facility Corrections
State surveyors classified this incident as "immediate jeopardy"—the most serious category of violation, indicating a situation that has caused or is likely to cause serious injury, harm, impairment, or death. The designation applied from January 17 through January 20, when the facility implemented corrective actions.
Facility administrators suspended NA-B pending investigation and filed reports with the Office of Health Facility Complaints and local law enforcement. An Ad Hoc Quality Assurance and Performance Improvement meeting was convened, and the facility's medical director confirmed "there was no tolerance for such situations."
Corrective measures implemented included mandatory staff education with associated quizzes covering abuse prevention, safe patient handling, resident rights, and care planning. The facility initiated observation audits of transfers and resident treatment, and reviewed care plans for all residents with similar transfer needs to ensure current accuracy.
The facility's Safe Resident Handling Program policy explicitly required that when mechanical lifting equipment was determined necessary, "the lift was to be used in all circumstances unless absolutely necessary i.e. emergency situations." The policy also mandated use of transfer belts during stand-pivot transfers—neither requirement was followed in this case.
Additional Issues Identified
A second immediate jeopardy violation was identified involving inadequate supervision to prevent elopement. On January 11, 2025, a resident at risk for wandering removed her monitoring device and exited the facility, remaining outside in 17-degree weather for approximately 30 minutes. Staff had failed to conduct required monitoring checks despite documenting completion, and no immediate action was taken to replace the device or notify management when it was discovered missing. The resident was found a block away from the facility, crying and stating she was lost. This violation was also corrected prior to the survey and issued as past non-compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Villa At Osseo from 2025-01-24 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.