A Minnesota assisted living facility has been found negligent for a resident death that occurred two days after the resident sustained a head injury during a transfer from an electric wheelchair to a bed using a mechanical lift and sling owned by the resident.

GoldPine Home in Bemidji, MN, “failed to adequately train staff, failed to determine the appropriate sling size, and failed to maintain the mechanical lift according to manufacturer’s recommendations,” the Minnesota Department of Health said in a 29-page report issued Dec. 26.

In a statement to McKnight’s Senior Living, GoldPine said it could not comment on the incident because the resident’s family has hired an attorney and may file a lawsuit. The facility has been serving Bemidji for more than 20 years, the statement noted. GoldPine had 59 residents at time of the health department survey, according to the report.

“We are saddened by the loss of any of our residents, and GoldPine Home strives to provide top-quality senior housing and services with a commitment to each individual’s physical and emotional well-being,” the GoldPine statement said.

According to the health department report, two unlicensed workers were involved in the Aug. 7 evening transfer of a resident (not identified in the report) who had multiple sclerosis and was taking warfarin, a blood thinner, due to a history of a blood clot. During the transfer, the resident reportedly slipped out of the sling opening, hit his or her head on the leg of the lift and began bleeding from the head.

The resident died in a hospital two days later. “The death certificate indicated that as a consequence of falling from the mechanical lift, s/he died of a traumatic subdural hematoma (burst blood vessel). Contributing factors included warfarin therapy,” the report stated.

The health department said it made unannounced visits to GoldPine over three days in September, interviewing administrators, nursing staff and unlicensed staff; observing mechanical lift transfers; and reviewing the late resident’s medical record. The mechanical lift transfer also was re-enacted.

“During a staff interview, it was determined the preventative maintenance of the mechanical lift had not been performed,” the report said. “There was not a system in place to ensure the appropriate size sling. In addition, staff did not sign off when trained on the mechanical lift policy.”

GoldPine did not comply with Minnesota statutes related to providing competent staff, reporting an incident of neglect and treatment of residents, the health department said. The facility can appeal the maltreatment finding.

One of the unlicensed workers no longer is working at GoldPine, according to the report.