The incident occurred on October 16 at Foundation Park Care Center when Resident 12 got his arm under the lift's support sling while being transferred. Staff lowered him to the ground while his legs remained secured in the lift.
LPN 270 responded to assist the resident back into his wheelchair. She assessed him by feeling along his legs with her hands and found no obvious injury. The resident showed no signs of pain while on the floor or during the transfer back to his chair, and LPN 270 noted no bruising or visible leg displacement.
But the assessment was incomplete.
The next day, October 17, when LPN 270 returned to pass medications, she found the resident's hospice aide in the room. The aide reported something was wrong with the resident's leg.
LPN 270 reassessed and discovered the resident's right leg was rotated inward. A stat x-ray revealed a right femur fracture with severe dislocation. The resident was immediately sent to the hospital.
During interviews with federal inspectors on November 25, LPN 270 explained what she believed happened during the lift incident. After the resident was lowered to the floor with his legs still in the lift, "it was thought Resident 12's leg was broken when he threw himself to the side after being lowered to the ground."
The nurse admitted she did not complete a range of motion assessment following the incident. She also reported the resident did not bear weight during the transfer back to his wheelchair, a potential warning sign that went unexamined.
RN 238 was in the room with the wound care team when the incident occurred and witnessed the entire situation. She confirmed she also failed to complete a range of motion assessment for the resident.
"RN 238 stated she did not think Resident 12 was weight bearing at the time of the transfer," inspectors noted.
The facility's Director of Nursing confirmed that a range of motion assessment should have been completed following the incident. She was off duty the day it occurred and said RN 238, who witnessed everything, would have more information about what assessments were actually done.
None were.
The facility's own policy, titled "Free of Accidents/Hazards/Supervision, Devices" and revised in May 2024, defines a fall as "unintentionally coming to rest on the ground, floor, or other lower level but not as a result of an overwhelming force."
When a fall occurs, the policy requires staff to assess the resident for injuries, notify the physician, and provide treatment as necessary. Staff must also notify the resident's representative.
The policy requirements weren't followed. Despite having a registered nurse witness the entire incident and an LPN conduct the initial response, neither completed the range of motion assessment that might have detected the fracture immediately.
The resident spent 24 hours with an undiagnosed broken femur and severe hip dislocation. The injury was only discovered when an outside hospice aide noticed the resident's leg position looked wrong.
LPN 270 told inspectors she relied on LPN 270 to document any assessments that were completed. But the critical range of motion assessment that could have identified the fracture was never done by either nurse present.
The incident raises questions about staff training on lift safety and post-incident protocols. Mechanical lifts are designed to prevent falls, but when residents slip out of the slings or get limbs caught, the potential for serious injury increases significantly.
Federal inspectors cited the facility for failing to ensure residents remained free from accidents and received adequate supervision. The violation was classified as minimal harm with few residents affected.
The resident's current condition following hospitalization for the femur fracture and hip dislocation was not detailed in the inspection report. The hospice aide who ultimately identified the injury was not employed by Foundation Park Care Center, suggesting the fracture might have gone undetected even longer without outside intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foundation Park Care Center from 2025-11-25 including all violations, facility responses, and corrective action plans.