CHARLOTTE, NC - Federal inspectors cited Pelican Health at Charlotte for immediate jeopardy violations after a resident fell approximately three feet from a mechanical lift when a frayed strap broke during transfer, causing head trauma and emergency hospitalization.
Mechanical Lift Equipment Failure Results in Fall
On March 9, 2024, Resident #43 was being transferred from her bed to a shower chair using the facility's mechanical lift when one of the straps on the lift pad snapped in half. The resident fell to the tile floor, hitting her head and landing on her right side.
According to the federal inspection report, the broken strap was frayed, indicating the equipment had deteriorated before the incident. Nurse #3, who responded to the scene, observed Resident #43 lying on the floor with "a blank stare and was only responding to painful stimuli for approximately one minute."
The resident was found to have "a huge hematoma to the back right side of her head" and reported pain throughout her right side. Emergency Medical Services transported her to the hospital for evaluation, where CT scans and x-rays were performed. While no fractures were detected, the resident experienced acute respiratory insufficiency in the emergency department, suspected to be related to rib pain and narcotic administration.
Safety Protocol Violations Identified
The inspection revealed multiple failures in safety protocols surrounding the use of mechanical lifts. The manufacturer's instructions clearly state that operators must inspect the mechanical lift before each use, checking all hardware and examining the lift sling for wear or damage.
Nurse Aide #2, who assisted with the transfer, acknowledged that staff were supposed to check lift slings before every use to ensure straps were not frayed or torn. However, she was unable to confirm whether her colleague had properly inspected the sling before the transfer.
The facility's former Director of Maintenance confirmed that monthly inspections of all mechanical lifts and slings were conducted, but daily pre-use inspections were the responsibility of nursing staff. He stated he had not observed damaged slings during his monthly reviews prior to the incident.
Additional Safety Concerns with Lift Operations
During the inspection, surveyors observed another serious safety violation involving mechanical lift operations. On January 29, 2025, inspectors watched as staff failed to secure the wheel brake on a mechanical lift before transferring Resident #76. The base of the lift moved and shifted during the transfer, creating additional fall risk.
The manufacturer's instructions specifically require operators to "widen the base and engage the caster brake" before lifting residents. When the brake was not secured, the lift base moved during operation, demonstrating how protocol failures can compound safety risks.
Long-term Impact on Resident Well-being
The March 2024 incident has had lasting effects on Resident #43's quality of life. According to her interview with inspectors, she has received only a few showers since the fall because she experiences panic attacks when using the mechanical lift. Staff have been providing bed baths instead, but the resident expressed that she "really enjoyed taking a shower once or twice a week."
This psychological trauma demonstrates how equipment failures and safety violations can affect residents beyond immediate physical injuries. The fear and anxiety created by the incident have limited the resident's access to preferred hygiene care, potentially affecting her dignity and comfort.
Staffing and Training Deficiencies
The inspection revealed broader systemic issues beyond equipment failure. Multiple violations were identified related to registered nurse staffing requirements, with the facility failing to provide required RN coverage for 29 out of 389 days reviewed. This included complete absence of registered nurse coverage on numerous dates throughout 2024.
Inadequate staffing can compromise safety oversight and proper implementation of transfer protocols. When facilities operate with insufficient licensed nursing staff, the supervision and monitoring of complex care procedures like mechanical lift transfers may be compromised.
Infection Control Failures
Additional violations were documented in infection control practices. Inspectors observed a nurse performing wound care without following Enhanced Barrier Precautions, failing to wear required protective equipment and not performing proper hand hygiene between wound care steps.
These infection control failures represent additional safety risks for vulnerable residents. Proper wound care protocols exist to prevent healthcare-associated infections, which can be particularly dangerous for elderly nursing home residents with compromised immune systems.
Medical Equipment Safety Requirements
Mechanical lifts are essential equipment in nursing homes for safely transferring residents who cannot move independently. Federal regulations require facilities to maintain equipment in safe working condition and train staff in proper operation procedures.
Pre-use equipment inspections are critical safety measures designed to identify worn or damaged components before they fail during use. When these inspections are not performed consistently or effectively, residents face increased risk of injury from equipment failure.
The presence of frayed straps indicates gradual deterioration that should have been detected through regular inspection protocols. Mechanical lift slings experience stress during each use and must be regularly examined for signs of wear that could lead to failure.
Regulatory Response and Facility Actions
The facility's immediate jeopardy designation was removed on March 10, 2024, after implementing corrective measures. These included conducting competency assessments for the involved staff members, providing education on lift inspection procedures, and establishing monitoring systems.
However, inspectors noted that the facility was unable to locate documentation of the initial safety audit conducted after the incident or provide evidence of ongoing monitoring since March 2024. This documentation gap raises questions about the sustainability of implemented safety measures.
The facility came under new ownership on December 16, 2024, which may have affected record keeping and continuity of safety programs. The Administrator acknowledged that corporate recruiters were working to address nursing staff shortages that contributed to coverage gaps.
Industry Standards and Best Practices
Professional nursing home standards require comprehensive equipment maintenance programs and staff training protocols. The Centers for Disease Control and Prevention provides guidance on safe patient handling practices, including specific requirements for mechanical lift operations.
Best practices include documented pre-use equipment checks, regular staff competency assessments, and immediate removal of damaged equipment from service. Facilities should maintain detailed records of equipment inspections and staff training to demonstrate ongoing compliance with safety requirements.
The violations at Pelican Health highlight the importance of consistent implementation of safety protocols and adequate staffing levels to ensure proper oversight of complex care procedures. When multiple systems fail simultaneously, residents face compounded risks that can result in serious injuries and long-term trauma.
Federal regulations exist specifically to prevent incidents like the mechanical lift failure at Pelican Health. The immediate jeopardy designation reflects the serious nature of these violations and their potential to cause significant harm to vulnerable nursing home residents.
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.
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