Inspection Report

Baptist Health Care Center Transfer Safety Harm ND

September 13, 2025

Bismarck, ND

357 views

BISMARCK, ND - Baptist Health Care Center implemented immediate corrective measures and placed a certified nursing assistant on administrative leave after a transfer safety incident that resulted in a resident being sent to the emergency room in December 2024.

Transfer Safety Breach Leads to Emergency Room Visit

The incident at Baptist Health Care Center involved improper transfer techniques that violated federal safety standards for nursing home residents. According to the inspection report, a certified nursing assistant failed to follow proper gait belt procedures and transfer protocols when moving a resident, resulting in an incident serious enough to require emergency medical attention.

The facility's inspection documents reveal that the violation was classified as causing "actual harm" to residents, indicating that the safety breach had real consequences for patient wellbeing. The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility.

Medical Significance of Proper Transfer Techniques

Safe patient transfers are fundamental to nursing home care, particularly for elderly residents who may have compromised mobility, balance issues, or fragile bone structures. Gait belts are essential safety devices designed to provide caregivers with a secure grip when assisting residents with movement, reducing the risk of falls and injuries during transfers.

When transfer protocols are not followed correctly, residents face significant risks including falls, fractures, bruising, and potential head injuries. Elderly residents are particularly vulnerable due to factors such as decreased bone density, medication effects that may impact balance, and underlying medical conditions that affect stability and coordination.

The failure to use proper transfer techniques can result in serious injuries that may require hospitalization, extended recovery periods, and in some cases, permanent disability. For nursing home residents, even minor falls can have major health consequences and significantly impact their quality of life.

Facility Response and Corrective Actions

Baptist Health Care Center took immediate action following the incident, implementing several corrective measures to address the safety violation. The facility placed the involved certified nursing assistant on administrative leave pending further investigation and mandatory education.

The nursing home conducted comprehensive staff education, providing immediate training to all staff members working in the affected area about proper gait belt use and transfer procedures. Additionally, the facility implemented facility-wide education through their notification system, ensuring all direct care staff received updated training on transfer safety protocols and the importance of following individual resident care plans.

The facility also established new competency requirements, mandating that all direct care staff complete skill assessments related to gait belt use and proper transfer techniques for wheelchair transfers. This ensures that staff members demonstrate proficiency in safe transfer methods before providing direct patient care.

Enhanced Training and Prevention Measures

As part of their corrective action plan, Baptist Health Care Center updated their orientation procedures to include comprehensive training on gait belt use and transfer techniques for both new employees and traveling staff members. This systematic approach helps ensure that all caregivers, regardless of their employment status, receive consistent training on safety protocols.

The facility conducted an in-depth root cause analysis to identify underlying factors that contributed to the incident. This analytical approach helps nursing homes understand not just what happened, but why it occurred, enabling them to implement more effective prevention strategies.

Industry Standards for Transfer Safety

Federal nursing home regulations require facilities to maintain comprehensive policies and procedures for safe resident transfers. These standards mandate that staff members follow established protocols, use appropriate safety equipment, and adhere to individual resident care plans that specify transfer requirements based on each person's mobility level and medical conditions.

Proper documentation and staff training are essential components of compliance with these regulations. Nursing homes must ensure that all staff members are competent in transfer techniques and understand the specific needs of each resident they serve.

Additional Issues Identified

The inspection documentation indicates this violation was part of a broader review of facility practices. The corrective actions implemented suggest that the facility recognized the need for systematic improvements in staff training, competency assessment, and safety protocols to prevent similar incidents in the future.

The facility's response included immediate notifications to the resident's provider and family representative, demonstrating appropriate communication procedures during medical emergencies. The comprehensive nature of the corrective action plan reflects the facility's commitment to addressing both the immediate incident and underlying systemic issues.

The violation was ultimately classified as past non-compliance, indicating that Baptist Health Care Center successfully implemented the required corrective measures to address the deficiencies identified during the inspection process.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Baptist Health Care Center from 2025-01-02 including all violations, facility responses, and corrective action plans.

Additional Resources

Editorial Standards

Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).

Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.

Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.

Last verified: June 21, 2026 · Our methodology

Quick Answer

BAPTIST HEALTH & REHAB in BISMARCK, ND was cited for violations during a health inspection on January 2, 2025.

The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility.

Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.

Frequently Asked Questions

What happened at BAPTIST HEALTH & REHAB?

The incident prompted an immediate investigation and comprehensive review of transfer safety procedures throughout the facility.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in BISMARCK, ND, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from BAPTIST HEALTH & REHAB or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 355058.

Has this facility had violations before?

To check BAPTIST HEALTH & REHAB's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.