Certified Nursing Assistant #6 was attempting to move Resident #3 from bed to a recliner chair using a hoyer lift when the equipment failed. The resident fell out of the lift canvas and onto the floor.
Another nursing assistant, Certified Nursing Assistant #7, walked into the room during the incident and helped pick the resident up off the floor and place them back in bed. Both staff members then notified the charge nurse about what had happened.
The facility terminated Certified Nursing Assistant #6 for not following the resident's plan of care. Certified Nursing Assistant #7 received a suspension for failing to notify supervisors before moving the resident from the floor back to bed.
When interviewed on October 31st, Certified Nursing Assistant #6 explained they had tried to find help before attempting the transfer alone. They said the other four nursing assistants on the unit were busy with their assigned residents, and the two nurses were occupied giving medications.
"They knew they should call for another staff to help and they tried to look for someone but could not readily get anyone," according to the inspection report. The assistant said they thought "Resident #3 had been in bed too long, so they just went ahead and did it alone to ensure Resident #3 was taken out of bed on time."
Certified Nursing Assistant #7 told inspectors they were suspended for helping to pick up the resident. They confirmed that Certified Nursing Assistant #6 had not called them to help with the mechanical lift transfer.
Licensed Practical Nurse #1 was waiting to assist Certified Nursing Assistant #7 with another resident's shower when they learned about the fall. The nurse said Certified Nursing Assistant #7 came to inform them that "Resident #2 fell when Certified Nursing Assistant #6 was trying to transfer resident from bed by themself with the mechanical lift."
The confusion over resident numbers in staff accounts suggests the incident created immediate chaos on the unit.
Licensed Practical Nurse #1 noted that Certified Nursing Assistant #6 failed to call for help before using the mechanical lift and did not notify nursing staff before the resident was placed back in bed after the fall.
Registered Nurse Manager #1 responded to the incident around 2:00 PM that day. By the time they reached the resident's room, the person had already been moved back to bed by the nursing assistants.
During assessment, the nurse manager observed concerning signs. The resident showed "decreased passive range of motion on the right lower extremity with facial grimacing when gentle passive range of motion was attempted."
The nurse manager told inspectors they were not informed about the incident before the resident was placed back in bed, a violation of facility protocol requiring immediate supervisor notification when a resident is found on the floor.
Director of Nursing confirmed the disciplinary actions during an interview on November 3rd. Certified Nursing Assistant #6 was terminated for not following the resident's plan of care, while Certified Nursing Assistant #7 was suspended for not following facility protocol about notifying supervisors when observing a resident on the floor.
The incident highlights staffing pressures that can lead to dangerous shortcuts in resident care. Mechanical lifts require two staff members to operate safely, but the nursing assistant felt compelled to proceed alone rather than leave the resident in bed longer.
The resident's facial grimacing and decreased range of motion suggest the fall may have caused injury, though the extent of harm was not detailed in the inspection report.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. The facility's failure to ensure proper transfer procedures and immediate incident reporting created risks that extended beyond this single event.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brooklyn Ctr For Rehab and Residential Health Care from 2025-11-04 including all violations, facility responses, and corrective action plans.
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