Staff member H told federal inspectors she was "aware that only using one person for transferring residents with a mechanical lift was not the right way to provide the care." She used the Hoyer lift alone anyway.
The violations came to light during a September complaint investigation. Resident #1's care plan, dated August 5, 2022, explicitly stated the patient was "totally dependent upon two staff members for transferring her from surface to surface" using a Hoyer fully body mechanical lift.
Multiple workers admitted they knew better but did it anyway due to understaffing.
"I knew I should have a second person because I was trained and have always had two people for lifts," nursing aide NF1 told inspectors on September 22. NF1 had never used a mechanical lift alone before working at the facility.
Staff member H revealed the facility had reduced staffing to just one certified nursing assistant per hall. "It upset her when the staffing was changed to having only one CNA in each hall," according to the inspection report.
The staffing cuts forced workers into an impossible choice. "The residents had to get taken care of, so we had to do what we could to get the residents taken care of, and that included using the mechanical lifts by ourselves," staff member H said.
Long-term employee staff member L described the staffing shortage as chronic. "It was never 100% for getting two staff to help," he told inspectors. "Most of the time he had two staff doing the lifts, but sometimes the facility is short-staffed and two staff are not always available."
L said he had received training on the lifts and "had been using lifts for a long time, so he knows how to use them." Experience, however, doesn't eliminate the safety risks of solo operation.
Mechanical lifts require two people for fundamental safety reasons. One person operates the lift controls while the second ensures the resident remains properly positioned and secure throughout the transfer. A single operator cannot simultaneously control the lift and monitor the resident's safety.
The facility's own training emphasized this requirement. Every worker interviewed confirmed they had been taught to use two people when operating mechanical lifts for resident transfers.
Staff member H specifically told inspectors "she was taught to use two people when using a mechanical lift to transfer people." The training wasn't ambiguous or unclear.
The violation affects vulnerable residents who depend entirely on staff for mobility. Resident #1 was classified as "totally dependent" for transfers, meaning any error during lift operation could result in serious injury.
Single-person lift operation creates multiple hazard points. The resident could slip from the sling, the lift could tip due to improper positioning, or the operator could lose control while trying to manage both the equipment and the resident simultaneously.
The inspection found these safety violations were not isolated incidents but part of a pattern driven by deliberate understaffing decisions. Reducing each hall to one nursing assistant made proper lift protocols impossible to follow consistently.
Workers found themselves caught between competing demands: follow safety protocols and leave residents unattended, or violate training to provide basic care. The facility's staffing model forced them to choose the latter.
The September 24 inspection classified the violation as causing "minimal harm or potential for actual harm" to residents. However, mechanical lift accidents can cause severe injuries including fractures, head trauma, and soft tissue damage.
Staff member H's statement revealed the emotional toll of the situation. She expressed being "upset" about the staffing changes but felt compelled to provide care however possible.
The facility's approach essentially transferred liability for unsafe practices from management to front-line workers. Staff knew the protocols, received proper training, but were placed in impossible situations by inadequate staffing.
Federal inspectors found the facility "failed to ensure services were provided according to professional standards related to safe use of mechanical lifts." The violation encompassed both the unsafe practices and the systemic understaffing that necessitated them.
The inspection occurred in response to a complaint, suggesting someone reported concerns about lift safety or witnessed unsafe transfers. The specific nature of the complaint was not detailed in the report.
Wibaux County Nursing Home operates in a rural Montana community where finding qualified nursing staff presents ongoing challenges. However, staffing difficulties don't excuse violations of basic safety protocols designed to protect vulnerable residents.
The facility must now develop and implement a plan of correction addressing both the immediate safety violations and the underlying staffing issues that created them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wibaux County Nursing Home from 2025-09-24 including all violations, facility responses, and corrective action plans.