St. John’s Lutheran Home of Albert Lea was issued a federal deficiency after a resident was being transferred by a lift earlier this year and fell, according to a Minnesota Department of Health investigative report made public last month.

According to the report, the facility has since come into compliance.

St. John’s Administrator Scott Spates called the occurrence an “isolated incident,” and noted that after it happened, facility officials reported it to the Department of Health.

“In any kind of accident with a resident like that, it’s very serious,” Spates said.

Facility officials also conducted their own investigation into the incident and have since made some changes to policies and assessments of residents, he added.

According to the Department of Health report, the resident fell on April 26. She was being transferred using a Hoyer lift with the assistance of one aide.

Though the resident’s most recent physical therapy assessment indicated that she required the assistance of two people on all transfers, her care plan had been changed to use the assistance of only one person. The staff person making that change did not document the criteria used to make the change, the report states.

According to the facility policy, the resident did not meet the requirements set for a one-person transfer with a Hoyer lift; for a mechanical lift transfer with one staff member, the resident must be able to follow directions and be cooperative.

This resident had a history of being “severely restless” and agitated, the report stated. She used psychotropic medications on a regular basis.

Spates said since the incident the facility has added criteria for how nurses assess residents, to determine whether they need assistance by one or two people. The nurse who assessed the resident in this case has also been re-educated on policies and assessments.

He said nurse aides have completed a performance competency test, including random audits, to make sure they know how to use all of the equipment.

The nurses have also reviewed all of the care plans for residents who are listed as needing help by one aide to make sure this amount of assistance is appropriate.