A physical therapist assistant witnessed the dangerous techniques and told inspectors on December 31 that she "did see the aides transfer by hooking under the arms." The assistant said she wasn't sure about all the consequences, "but it could hurt the shoulder."
The facility's own physical therapist confirmed the dangers. Aides "did not want to lift residents by the shoulders because the aides needed more control and it was not safe," the PT told inspectors. Staff "needed to be careful with the arms because it could pull or dislocate the arm."
The PT said proper two-person transfers required "someone in front of the resident and someone behind the resident controlling the transfer from the resident's hips." Using gait belts while "grabbing the waistband was not the safest and did not give enough control."
Director of Nursing confirmed the facility trained staff on proper transfer techniques. She acknowledged that "hooking an arm under the resident's arm was uncomfortable could cause skin tears and bruising and it was not a safe transfer." Grabbing residents by the waistband "could cause a wedgie and was not comfortable."
When two nursing assistants demonstrated proper technique for inspectors, they correctly placed gait belts around the director's waist and held her forearms during transfers.
The director admitted transfers were "not continuously monitored" despite the documented training failures. The assistant director responsible for transfer training was "out of town on vacation and unable to be reached" during the inspection.
The facility's own policy emphasized protecting "safety and wellbeing of staff and residents" through appropriate lifting techniques, but inspectors documented staff routinely ignoring these protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robert Lee Care Center from 2025-12-31 including all violations, facility responses, and corrective action plans.
