The October 11 incident at Pleasant View Luther Home involved a resident assessed as having moderate fall risk just two days earlier. The resident's spouse requested emergency room transport after the fall.
Certified Nursing Assistant V8 had transferred the resident to the toilet using a sit-to-stand mechanical lift, following the facility's required procedure. But then V8 unhooked the resident from the lift entirely and raised the enabler bar to provide more room during incontinence care.
The resident was unable to maintain posture and balance on the toilet without the safety equipment. The resident leaned to one side and fell to the floor.
V8 told inspectors on November 15 that he "put the resident's pull-up and pants back on, then lifted his feet to put them on the sit-to-stand, and the resident fell off the toilet." V8 admitted he "put the resident's feet onto the sit-to-stand first instead of applying the top harness."
The facility's mechanical lift policy requires staff to position the harness around the resident's upper body and securely fasten the safety strap around the chest. When lifting from a wheelchair or chair, staff must secure the harness loops onto the lift and secure shin straps around the resident's legs.
V8 acknowledged he should have applied the top harness and attached it to the lift before lifting the resident's feet onto the foot pedal. He confirmed the resident was unable to balance or stand without assistance.
The facility's root cause analysis determined the resident had impaired mobility and poor sitting and standing balance. The analysis noted the team member had placed the enabler bar in the upward position to provide more room during personal hygiene care and was unable to prevent the fall.
Another nursing assistant, V6, explained that enabler bars in bathrooms are designed for residents who can stand independently but may need some assistance with standing and balancing. This resident clearly did not meet that description.
The facility's fall prevention policy requires staff to evaluate functional and psychological factors that increase fall risk, including mobility, gait balance, and activities of daily living capabilities. The resident's fall risk assessment, completed just two days before the incident, had identified moderate fall risk.
Pleasant View Luther Home provided team member education regarding the use of enabler bars and safety awareness when providing care for residents with impaired sitting and standing balance following the incident.
The facility failed to implement required safety interventions for the resident during toilet transfers, despite having policies that clearly outlined the proper procedures for mechanical lift use and fall prevention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pleasant View Luther Home from 2025-11-15 including all violations, facility responses, and corrective action plans.