The incident occurred when nursing assistant #1 and nursing assistant #2 attempted to move Resident #5 from his wheelchair to his bed using the facility's mechanical lift. The lift became stuck around the resident's wheelchair, forcing the East Unit Manager to maneuver the wheelchair from side to side to free it from the equipment.
Despite the obvious mechanical problem, both nursing assistants proceeded with the transfer without taking basic safety precautions required for mechanical lift operations.
Nursing assistant #5, who participated in the transfer, told inspectors she connected the sling to Resident #5 and guided his legs while her colleague controlled the lift. She admitted she "did not think to look at the lift to assure the base was in a widen position or if the wheels were locked while connecting the resident to the lift."
The second nursing assistant, reached by phone during the inspection, acknowledged she knew the proper procedure. She told inspectors that transferring a resident using a mechanical lift "should include widening the base of the mechanical lift, placing the lift around the wheelchair and locking the wheels to the lift."
But she could not recall following those steps. "NA #2 reported she could not recall opening the base or locking wheels to the mechanical lift," inspectors wrote.
The East Unit Manager, who intervened when the lift became stuck, recognized the safety violation after the fact. She told inspectors that "if the base was in widened position, she could have removed the wheelchair with more ease." Like the nursing assistants, she admitted she "did not think to widen the base of the mechanical lift or lock the wheels to the mechanical lift at the time."
The facility's Director of Nursing confirmed that all three staff members violated established protocols. She told inspectors that "NA #2, NA #5, and the East Unit Manager should have widened the base and locked the wheels to the mechanical lift when transferring Resident #5."
The timing of the violation proved particularly troubling. Staff had received education about mechanical lift transfers just days before the incident occurred. The Director of Nursing revealed that "the staff were just educated regarding Mechanical lift transfers" shortly before the September 17 transfer that prompted the complaint.
The facility's Administrator told inspectors that staff receive training on mechanical lifts both when hired and "on an as needed basis." She said she "expected staff to follow the policy for mechanical lift transfers."
Federal inspectors classified the violation as having caused "minimal harm or potential for actual harm" to residents. The failure to properly secure mechanical lifts during transfers creates significant fall risks for residents, who are often unable to support their own weight during the transfer process.
Mechanical lifts are designed with safety features specifically to prevent accidents during transfers. Widening the base provides stability, while locking the wheels prevents the equipment from moving unexpectedly during the transfer. When staff skip these steps, residents face the risk of being dropped or falling if the equipment shifts or becomes unstable.
The inspection report does not indicate whether Resident #5 suffered any injuries during the unsafe transfer. The incident came to light through a complaint filed with state regulators, though the report does not specify who filed the complaint or when it was submitted.
The violation occurred despite recent training and established policies requiring proper mechanical lift procedures. Three different staff members, including a unit manager, all failed to follow basic safety protocols they had been trained to implement.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.