The incident occurred when the agency CNA lined up a shower stretcher next to the resident's bed and pulled them across using a sheet. "The aide pulled the resident with the sheet the stretcher moved away and I fell on the floor, I knew my arm was broke," the resident told state inspectors on November 6.
The resident was immediately transported to the hospital with a fractured left upper arm.
Facility policy required two staff members for all mechanical lift transfers. Every CNA receives assignment sheets before each shift that specify whether residents need one or two-person assistance for transfers, according to the unit manager and licensed practical nurse interviewed by inspectors.
The agency nursing assistant was terminated and accepted full responsibility for the fall, according to the facility's investigation. The Director of Nursing confirmed that help was available on the unit when the incident occurred.
"The resident was a mechanical lift transfer and help was available," the Director of Nursing told inspectors. "He was educated that we don't attempt to maneuver unless they get help."
Other staff members demonstrated clear understanding of safety protocols. When inspectors observed a CNA pushing a mechanical lift down the hallway, the worker explained proper procedure: "You always need two people, if you don't have two people you don't use it until you do."
A unit CNA told inspectors that getting assistance was never a problem because "the Unit Manager would always help." Assignment sheets clearly marked which residents required one or two-person assistance, she said.
The unit manager who was present during the incident said the terminated CNA "should have had two people in the room with him." She noted that the shower bed's brakes were tested after the fall and found to be in working order, raising questions about whether they had been properly engaged during the transfer attempt.
CNAs have multiple ways to access resident transfer requirements, including assignment sheets and electronic medical records that contain detailed care information, the Director of Nursing explained. The facility's mechanical lift policy, though undated, explicitly required two staff members for all transfers.
The agency worker did not return inspectors' phone call requesting an interview.
Federal inspectors cited the facility for failing to ensure residents received care in accordance with professional standards, noting the violation caused actual harm to the resident. The facility's own investigation concluded that the CNA "did not properly follow the resident's Plan of Care for transfer resulting in the increased risk for falls."
The resident's account of the incident highlighted the preventable nature of the injury. What should have been a routine transfer to a shower stretcher became a traumatic fall that required immediate hospitalization and left the resident with a fractured arm.
Despite clear policies requiring two-person assistance for mechanical lift residents and readily available help on the unit, the agency nursing assistant chose to attempt the transfer alone using an improvised sheet method rather than following established safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whiting Gardens Rehabilitation and Nursing Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
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