Dinwiddie Health And Rehab Center

of left shoulder and wrist.

Orders were implemented for wrist splint, immobilization with sling, ice/elevation, pain management and orthopedic referral. 7/9/25 - The mechanical lift used at the time of the incident was removed from service and inspected by maintenance with no malfunctions identified.

All mechanical lifts in the facility were inspected by maintenance with no identified problems.

All lift slings were inspected with five removed from use.7/9/25 - Statements were obtained from staff involved. A re-enactment of the incident was conducted with CNAs involved with the incident. Re-enactment of the incident revealed that the lift sling straps were not crossed as required for safety.

Education was immediately provided to the CNAs involved with the incident including procedure for crossing sling straps between the resident's legs. CNA #4 went home after the incident due to being upset about the incident.

Care plans were reviewed for all residents with need for 2-person assistance for accuracy and current competencies were reviewed for accuracy.7/10/25 - 7/12/25 - CNA competencies regarding proper use of the mechanical lift, sling straps and plans of care for transfers were conducted with all CNAs.

This was documented on a form titled Skills Checklist Using a Mechanical Lift with observations and sign-off of demonstrated proper procedures.7/16/25 - DON conducted in-service education with all CNAs and nurses regarding residents' transfer status and following the plan of care/kardex for proper transfer status.7/21/25 - DON or designee began random observations of five mechanical lift transfers weekly for four weeks with report of findings presented to the quality assurance committee.

Weekly audits were ongoing and to be reviewed by the quality assurance committee.Date of compliance was listed as 8/5/25.The education, competency checklists and lift transfer monitoring were documented as listed with weekly monitoring of lift transfers continuing during the current survey.

The audits since 8/5/25 indicated compliance with proper lift procedures including proper sling strap positioning.

There were no falls/incidents involving a mechanical lift since the correction date of 8/5/25.

There were six residents that had experienced a fall in the facility since 8/5/25.

These residents (R3, R4, R5, R6, R7 and R8) were included in the survey sample with no deficiencies identified related to falls/accidents. On 9/3/25 at 8:00 a.m., accompanied by CNA #2 and CNA #3, a mechanical lift/transfer with use of the U-shaped sling was observed with Resident #2.

Proper sling and strap positioning was observed along with proper lift operation for a safe transfer.

Twelve CNAs were interviewed on different shifts regarding education and competencies with all interviewed verifying the education provided and verbalizing knowledge about crossing the bottom straps when using the U-shaped sling.

The plan of correction was deemed acceptable and implemented as listed with no non-compliance identified regarding falls/accidents since the correction date of 8/5/25.This finding was reviewed with the administrator, DON, clinical service specialist and director of quality assurance on 9/2/25 at 2:50 p.m. and on 9/3/25 at 11:40 a.m. with no further information presented prior to the end of the survey.This deficiency was cited as past non-compliance.

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