An assisted-living facility in Bemidji has been found responsible for the August death of a resident with disabilities who fell from a mechanical lift and suffered a severe head injury.

In a report released Wednesday, state health investigators said GoldPine Home of Bemidji failed to adequately train staff and failed to operate a mechanical lift according to the manufacturer's standards, among other violations. As a result, a resident with multiple sclerosis fell out of the lift and hit her head on its metal frame.

The resident was rushed to the emergency room via ambulance and died two days later, according to an investigation concluded last month by the Minnesota Department of Health.

State health investigators also found that staff at GoldPine Home were not properly trained on how to use the mechanical lifts and did not report the incident of neglect to the state's maltreatment reporting system as required by law.

Staff at GoldPine Home did not return calls on Thursday.

According to the state report, the resident slipped out of a sling attached to a Hoyer lift while being transferred by unlicensed staff from her power wheelchair to her bed. The facility's director of nursing told state investigators that the three unlicensed staff involved in the transfer were trained by other unlicensed staff and that a registered nurse had never observed the staff members perform a Hoyer lift transfer.

In addition, the assisted-living facility did not have a system in place to ensure staff used the appropriate sling during transfers, and the facility's Hoyer lift policy "was not explicitly reviewed with staff as they do not sign off on it," state investigators found.

One of the GoldPine Home's staff members involved in the fatal transfer told state investigators that another unlicensed staff member was joking with the resident during the transfer and failed to steady the resident with his hands, but "was just cranking the machine up." The facility's Hoyer lift policy directed staff to guide a resident's body while using the sling, according to the state report.

The woman's death certificate indicated that she died from a traumatic subdural hematoma, or burst blood vessel, resulting from the fall.

The incident in Bemidji marks the latest in a string of deaths involving mechanical lifts at Minnesota senior homes.

In June, a caregiver at the Good Samaritan Society nursing home in Redwood Falls, in western Minnesota, was charged with manslaughter and criminal neglect after a 100-year-old resident died from injuries suffered after falling from a lift. And last year, two residents at another nursing home, Three Links Care Center in Northfield, died within months of each other after suffering falls from mechanical lifts.

Suzanne Scheller, an elder law attorney from Champlin, said the recent fatalities point to the need across Minnesota's senior care industry for greater monitoring of electronic lift transfers and the equipment being used.

"These are complex machines that require a significant amount of training," she said. "A [mechanical lift] transfer is also a very anxiety-producing and significant event in a resident's day. It definitely merits a sound review of equipment and training and staffing."