The incident occurred on September 8th when Qualified Medication Aide 2 used a Sara lift to transfer Resident B from a sitting to standing position onto her bed at Saint Anne Home. After completing the transfer, the aide repositioned the resident into a lying position by placing one arm behind the resident's right shoulder and her other arm under the resident's legs.
That's when Resident B heard a pop.
"She then felt a pop in her left arm and her left arm went numb," the resident told inspectors on October 1st. An X-ray revealed she had fractured her left humerus.
The resident suffers from anemia, obesity, hyperglycemia and chronic kidney disease. Medical orders from April required her to be transferred via Sara lift with two-staff assistance.
QMA 2 admitted to inspectors she performed the entire transfer and repositioning alone. "No other staff were present during the transfer nor repositioning," she told investigators. She acknowledged that two staff were required for all mechanical lift transfers, including Sara lifts.
But she claimed ignorance of the policy.
"QMA 2 indicated she had never been trained or educated on Sara lift transfer requirements," according to the inspection report.
The facility's own records contradict that claim. A signed validation checklist dated August 6th showed QMA 2 had received education and been checked off on all mechanical lifts, including sit-to-stand lifts. The checklist indicated that functions of the lift and requirements for two staff to be present during transfers were specifically discussed with her.
The Administrator confirmed QMA 2 performed the Sara lift transfer and repositioned Resident B alone without additional staff present. The Administrator acknowledged two staff were required during Sara lift transfers.
Certified Nurse Assistant 3 explained the policy to inspectors: all mechanical lifts, including Sara lifts, required a two-person assist. Even after the transfer was completed, two staff were required to reposition a resident from sitting to lying position in bed.
The facility's written policy, dated January 2025 and titled "Safe Resident Handling/Transfers," clearly states that two staff are required to assist with all mechanical lifts.
A facility incident report documented the September 8th transfer. It noted that during Resident B's transfer, the staff member heard a pop noise. The resident was assessed and an X-ray confirmed the fracture.
An interdisciplinary team note from September 16th provided additional details about the incident. It confirmed QMA 2 heard the pop noise during the transfer process and that QMA 2 had used the Sara lift to move Resident B onto her bed. The note specified that after the transfer, QMA 2 repositioned Resident B by placing her arm behind the resident's right shoulder and her other arm under the resident's legs.
The Sara lift is a sit-to-stand mechanical device designed to help residents move from a seated position to standing and then to another location like a bed or chair. These lifts are commonly used for residents who have some weight-bearing capacity but need assistance with transfers.
Federal regulations require nursing homes to ensure that nurses and nurse aides have appropriate competencies to care for every resident in a way that maximizes each resident's wellbeing. The violation at Saint Anne Home was classified as causing minimal harm or potential for actual harm, affecting few residents.
The incident represents a breakdown in basic safety protocols. Despite having a clear two-person policy, documented training records, and a resident with specific transfer orders requiring two-staff assistance, QMA 2 attempted the transfer alone.
The consequences were immediate and painful for Resident B, who now must recover from a fractured arm that could have been prevented by following established safety procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Saint Anne Home from 2025-10-01 including all violations, facility responses, and corrective action plans.