Pilgrim Manor: Agency CNA Fractures Resident's Arm - LA

The incident occurred July 14, 2025, at Pilgrim Manor Skilled Nursing and Rehabilitation when agency CNA S6 used a "stand and pivot method" to transfer Resident #1, who required a Hoyer lift for all transfers.

During the transfer, the resident told the nursing assistant "she hit her arm on the wheelchair and complained of pain." An X-ray revealed a fracture.

The agency CNA admitted she "did not know Resident #1 was to be transferred with a Hoyer lift until after the incident" and "did not know how to look up a resident's transfer abilities until after the incident."

S6 had arrived late to work that morning after calling her agency to cover for a staff member who called in late, according to Assistant Director of Nursing S5. The ADON reported scheduling staff for the resident's hall and being called to respond when the incident occurred.

Resident #1 "could not do anything on her own and required the Hoyer lift for transfers," according to S14, the facility's registered nurse and wound care specialist. She noted there should have been a sign over the resident's door indicating the Hoyer lift requirement.

The facility's orientation policies required all agency CNAs to receive training on accessing resident charts and locating transfer ability information before working. Quality Improvement Nurses S1 and S2 confirmed agency staff must sign an Agency Facility Orientation sheet indicating they were oriented to the facility's charting system.

S6 had worked at Pilgrim Manor before. Records showed she first worked at the facility April 14, 2025, then didn't return until July 1, 2025. Between July 1 and the July 14 incident, she worked six shifts at the facility.

Documentation from those July shifts showed "proficient use by the CNA of resident's care guides," according to Quality Improvement Nurse S2, who reviewed S6's work history.

Despite this documented proficiency with the charting system, S6 told inspectors she transferred the resident using the stand-and-pivot method without checking transfer requirements. She reported being "in-serviced regarding obtaining information regarding proper transfer after the incident."

The Assistant Director of Nursing told inspectors she was informed the resident "was transferred using a lift and pivot method" and admitted she "did not recall Resident #1's transfer abilities without reviewing Resident #1's record."

Federal inspectors determined the facility failed to ensure agency staff were properly trained and supervised, resulting in actual harm to the resident. The violation affected few residents but caused significant injury requiring medical intervention.

The incident highlights gaps in oversight of agency nursing staff, who may work sporadically at facilities and require reinforcement of safety protocols between assignments. S6's three-month absence between her initial shift and return to the facility raised questions about whether additional orientation was needed.

The resident's fracture required immediate medical attention and ongoing treatment, demonstrating how improper transfer techniques can cause serious injury to vulnerable nursing home patients who depend entirely on staff for safe mobility assistance.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Pilgrim Manor Skilled Nursing and Rehabilitation from 2025-09-03 including all violations, facility responses, and corrective action plans.

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