WILKES BARRE, PA - State inspectors found that River View Nursing and Rehabilitation Center failed to conduct a thorough investigation after a resident with bilateral below-knee amputations was injured in a fall during an improper transfer, raising concerns about safety protocols and incident response procedures.
Transfer Protocol Violations Lead to Resident Injury
The April 2025 inspection revealed serious deficiencies in how staff handled the transfer of Resident 57, a patient with end-stage renal disease who required dialysis and had bilateral below-knee amputations. The resident's care plan and physician's orders specifically required the use of a mechanical lift with two staff members for all transfers, yet agency nurse aide Employee 14 attempted the transfer alone without the required equipment.
On December 13, 2024, at approximately 2:30 PM, Employee 14 manually lifted Resident 57 under both arms during a wheelchair transfer. During this improper transfer, the resident's left below-knee amputation stump became stuck in the wheelchair arm. When Employee 14 called for help, the maintenance director assisted in freeing the resident's stump, but Employee 14 then lost balance due to clutter on the floor and placed the resident on the ground to prevent further harm.
The resident told inspectors during the survey that "he had informed Employee 14 he required a mechanical lift with two-person assistance, but the aide proceeded to transfer him manually" and believed the aide was "in a hurry to get the transfer done faster."
Medical Consequences and Standards of Care
The improper transfer resulted in documented injuries to Resident 57. A nurse's progress note from December 14, 2024, documented complaints of rib pain, prompting an x-ray order. While the December 17 radiology report showed no fracture, a physician noted on December 19 that the resident likely had a right rib contusion based on continued pain despite negative x-ray findings.
The resident required Tylenol for rib pain on multiple occasions between December 14-20, 2024, with reported pain scores ranging from 3 to 8 on a 10-point scale. This injury was entirely preventable had proper transfer protocols been followed.
Mechanical lifts are specifically designed to safely transfer individuals with limited mobility while reducing injury risk to both residents and staff. For residents with amputations like Resident 57, proper transfer techniques are critical because their altered body mechanics and balance require specialized handling. The two-person assist requirement ensures one staff member can operate the lift while another provides additional support and monitoring.
The use of mechanical lifts follows established industry standards for preventing falls and transfer-related injuries. These devices distribute weight evenly and provide controlled, stable movement that manual transfers cannot match, particularly for residents with complex medical conditions.
Investigation Failures Compound Safety Concerns
The facility's response to the incident revealed significant gaps in their investigative procedures. Despite having policies requiring thorough investigation of all possible incidents of abuse, neglect, or mistreatment, the facility failed to conduct an adequate inquiry into the circumstances surrounding Resident 57's fall.
The investigation lacked several critical elements. Most notably, facility staff failed to obtain a statement from Resident 57 at the time of the incident, a fundamental oversight in any proper investigation. When questioned during the survey, the Nursing Home Administrator could not explain why the resident's account was not documented.
Additionally, the facility's investigation failed to identify that the required mechanical lift was not used or that only one staff member performed the transfer instead of the mandated two-person assist. The investigative report from Employee 14 did not acknowledge that physician orders and care plan requirements were violated during the transfer.
The facility also could not provide documentation explaining why Employee 14 left the facility, and attempts to re-contact this staff member during the inspection were unsuccessful. Employee 15, who assisted during the incident, stated he did not know why the aide was transferring the resident alone.
Regulatory Requirements and Facility Policies
Federal and state regulations require nursing homes to protect residents from abuse and neglect by implementing comprehensive prevention programs. Facilities must identify and investigate all possible incidents within required timeframes and ensure that care plans are properly implemented.
River View's own policy, last reviewed in January 2025, commits to protecting residents from abuse and neglect through facility-wide resource allocation and staff training. The policy specifically states that the facility will investigate and report any allegations within federally required timeframes.
Employee 14's personnel file confirmed completion of required training on proper transfer techniques and abuse and neglect prevention, with documented competency in performing assigned tasks. This makes the deviation from established protocols particularly concerning, as it represents a failure to apply known safety procedures rather than a lack of training.
The facility's care planning process had correctly identified Resident 57's transfer needs. His person-centered care plan, initiated in November 2024 and revised in December 2024, properly specified the requirement for mechanical lift transfers with two-person assistance. Physician's orders from December 6, 2024, clearly documented these same requirements.
Impact on Resident Safety and Care Quality
The violations identified represent more than administrative oversights - they reflect systemic failures that directly impact resident safety. When facilities fail to ensure care plan implementation, residents face increased risk of falls, injuries, and other preventable complications.
For residents with complex medical conditions like Resident 57, adherence to established protocols is essential for maintaining quality of life and preventing further health deterioration. Falls in nursing home residents can lead to serious complications including fractures, head injuries, and psychological trauma that can significantly impact recovery and independence.
The facility's failure to properly investigate the incident compounds these safety concerns by missing opportunities to identify system failures and implement corrective measures. Thorough incident investigation serves as a critical quality improvement tool that helps prevent similar occurrences.
Additional Issues Identified
The inspection also documented environmental hazards that contributed to the incident, including clutter on the floor and spilled water that created slip hazards during the transfer attempt. These conditions violated basic safety standards and demonstrated inadequate attention to maintaining safe resident environments.
The facility's task reporting system, while documenting the correct transfer requirements, was not effectively implemented to ensure compliance with established care plans. This represents a gap between policy documentation and actual practice that undermines resident safety.
The investigation revealed broader concerns about staff supervision and accountability, particularly regarding agency staff who may be less familiar with facility-specific protocols and individual resident needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timber Ridge Health Center from 2025-04-25 including all violations, facility responses, and corrective action plans.
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