The March 9, 2024 incident at Pelican Health at Charlotte left the woman with a huge hematoma on the back right side of her head and complaining that her whole right side hurt. She stared blankly for about a minute, responding only to painful stimuli before becoming more alert.
Nurse aides had been transferring Resident #43 from her bed to a shower chair using the mechanical lift when one of the left side straps on the lift pad broke. The woman "flipped out of the lift pad and landed on the floor," according to the incident report filed by Nurse #3, who responded when the aides called for help.
Emergency medical services transported the resident to the hospital, where CT scans of her head, chest and spine showed no acute trauma. X-rays of her pelvis, right leg and hip revealed no fractures. But she experienced acute respiratory insufficiency while in the emergency department, suspected to be related to rib pain or narcotic administration. She was admitted for observation and returned to the facility the next day.
The incident has left lasting trauma. When interviewed by federal inspectors nearly 11 months later, Resident #43 said she had received only a few showers since the fall because she was scared to use the mechanical lift. Staff had been giving her bed baths instead, though she "really enjoyed taking a shower once or twice a week." The few times she did use the lift for transfers, she had panic attacks.
"She stated staff were giving her bed baths, but she really enjoyed taking a shower once or twice a week," inspectors wrote. "The few times she received a shower and was transferred with the mechanical lift she had a panic attack."
Federal inspectors found the facility failed to follow basic safety protocols required by the lift manufacturer. The instruction manual clearly states operators must inspect the mechanical lift before each use, checking all bolts for tightness, examining sling hardware, ensuring all lift parts are in place, and checking the lift sling for wear.
Nurse Aide #2, who assisted with the transfer, told inspectors they were supposed to check lift slings before every use to make sure they were in good condition and the straps were not frayed or torn. But she was unsure whether her colleague had inspected the sling because it was already positioned under the resident when she entered the room.
"NA #2 indicated they were supposed to check the lift slings before every use to make sure the sling was in good condition and the straps were not frayed or torn," the inspection report states. "NA #2 revealed when they were lifting Resident #43 from the bed one of the straps on the lift sling snapped and Resident #43 slid out of the sling and fell approximately 3 feet to the floor hitting her head."
Nurse #3, who examined the broken equipment after the incident, observed that the failed strap was frayed, which caused it to rip in half. The damaged sling was immediately thrown in the trash after being inspected by the maintenance director and a nurse aide.
The Former Administrator told inspectors he initiated an investigation the day of the incident and determined the lift sling was damaged and the nurse aide had not inspected it prior to use. The Former Director of Maintenance said he inspected all mechanical lifts and lift slings monthly to ensure they were in good repair, but nursing staff were responsible for checking equipment before every use.
Federal regulators classified the incident as "immediate jeopardy" — the most serious level of violation — because of the high likelihood of serious injury when lift equipment fails during transfers. The designation was removed the next day after the facility implemented safety measures, but inspectors found the nursing home remained out of compliance at a lower level.
The facility's problems with lift safety extended beyond the broken strap. During the February 2025 inspection, surveyors observed another dangerous practice when Nurse Aide #2 and Nurse Aide #3 transferred a different resident using a mechanical lift without securing the wheel brake.
The manufacturer's instructions specify that operators should "widen the base and engage the caster (wheel) brake" before lifting. But during the observed transfer of Resident #76, the aide operating the lift failed to secure the brake. When she began raising the resident from the bed, "the base of the lift moved and shifted to the right."
The aide also failed to secure the brake before lowering the resident into the wheelchair, creating additional risk of the equipment moving during the transfer.
When questioned, Nurse Aide #2 said she thought she had secured the brake but didn't recall that it wasn't locked during the transfer. Nurse Aide #3 acknowledged it was the lift operator's responsibility to ensure the brake was secured but said she didn't notice her colleague had failed to do so.
Both the Director of Nursing and Administrator confirmed that staff should operate mechanical lifts according to manufacturer guidelines, including securing wheel brakes before lifting or lowering residents.
The facility also failed to accommodate the specialized needs of bariatric residents, providing wrong-sized briefs and no fitted sheets for two residents reviewed for accommodation of larger body sizes.
Additional violations included a resident receiving supplemental oxygen at 3.5 liters per minute without a physician's order, despite being on oxygen therapy for over a year. The Director of Nursing, Unit Manager, and treating nurse all acknowledged that oxygen therapy requires a doctor's order but were unsure why none existed.
Infection control failures occurred when a nurse performed wound care on a resident with a full-thickness wound without wearing the required gown for Enhanced Barrier Precautions. The nurse also failed to perform hand hygiene after removing the soiled dressing and cleaning the wound before applying a new dressing.
The nurse told inspectors she had forgotten to sanitize her hands between steps and was "doing the best that she could." She said she typically didn't perform wound care but was covering for the Wound Care Nurse who had called out that day.
For Resident #43, the consequences of the equipment failure continue nearly a year later. The woman who once enjoyed regular showers now faces them with terror, her basic dignity compromised by panic attacks triggered by the very equipment meant to help her maintain independence.
The facility implemented staff retraining and equipment audits following the incident, but inspectors noted they were unable to locate documentation of the initial safety inspections conducted after the fall or any ongoing monitoring since March 2024.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health At Charlotte from 2025-02-03 including all violations, facility responses, and corrective action plans.