The dangerous transfer occurred at Northeast Rehabilitation and Healthcare Center despite facility policy requiring two staff members to operate mechanical lifts at all times. Video footage captured the nursing assistant struggling with equipment that had wheels clogged with hair buildup.
CNA A told inspectors she knew the transfer was dangerous and that she "could not have prevented the mechanical lift from tilting over" if it became unbalanced. She acknowledged the resident "would have fallen and she could have been hurt."
The nursing assistant admitted she failed to check the lift's wheels before using it, despite knowing hair sometimes accumulated around them and prevented proper rolling. When the wheels wouldn't turn, she used force and pushed the lift sideways while trying to position its legs underneath the resident's bed.
"If the mechanical lift became unbalanced it could have tilted sideways," CNA A told inspectors during the August 20 interview. She said there was insufficient space in the room to maneuver properly.
CNA B, who was supposed to assist with the transfer, stepped away from the lift during the procedure, leaving CNA A to operate it alone. The Director of Nursing called this a clear violation of safety protocols.
"Neither should step away from the mechanical lift leaving one staff to operate," the DON explained. She said one staff member should operate the lift while a second guides the resident throughout the entire transfer.
The DON reviewed details of the observed transfer and confirmed the serious safety risk. "The mechanical lift could have tilted sideways causing Resident #1 to fall and possibly being injured," she said. "It would have been a fall that could have been avoided."
She emphasized that CNA A should have stopped the transfer, locked the mechanical lift, and requested help when problems arose. "It was not a safe transfer and one staff should never be left alone while operating the mechanical lift."
Video review by the administrator revealed the lift's wheels were actually rolling properly when CNA A pulled it back into the hallway. However, footage showed her using force and pushing the lift sideways when attempting to position it under the bed.
The administrator acknowledged that resident rooms had limited space but emphasized safety requirements. "He wanted to ensure the residents were transferred safely and based on the details he learned about Resident #1's transfer, it was not a safe transfer."
Maintenance staff and a lead CNA tested the mechanical lift after the incident. The wheels turned and rolled without problems. The maintenance supervisor confirmed a local company had recently serviced the lift and found no mechanical issues.
However, the lead CNA acknowledged experiencing difficulties maneuvering mechanical lifts when transferring heavier residents. "It was difficult to maneuver when a resident was heavier," she told inspectors.
The facility's policy explicitly requires two-person operation for all hydraulic lift transfers. The policy states: "Hydraulic lift: 2 person at all times."
This contradicts the manufacturer's user manual, which indicates their equipment "will permit proper operation by one assistant" based on healthcare professional evaluation for individual cases. The manual recommends two assistants for all procedures but doesn't require it.
CNA A told inspectors she had received multiple training sessions on mechanical lift operation and "knew better" than to perform the unsafe transfer. She acknowledged she would have been responsible if the resident had fallen.
The 300-pound resident remained in the lift throughout the dangerous transfer procedure. The incident occurred during a routine transfer from bed, with the nursing assistant struggling against equipment she knew was not functioning properly.
Federal inspectors classified the violation as having potential for actual harm to residents, though minimal harm occurred. The deficiency involved failure to ensure residents received treatment and care in accordance with professional standards of practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northeast Rehabilitation and Healthcare Center from 2025-08-21 including all violations, facility responses, and corrective action plans.
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