Failure to Prevent Accidents During Hoyer Transfer and Wheelchair Use
Penalty
Summary
A deficiency occurred when the facility failed to prevent accidents and provide adequate supervision for a resident with severe cognitive impairment and multiple comorbidities, including dementia, diabetes, and chronic kidney disease. The resident required a hoyer lift for transfers and was known to exhibit behavioral disturbances, such as moving and yelling during care. Despite these known behaviors, there was no specific care plan addressing the resident's actions during hoyer transfers. During one transfer, the resident was moving and manipulating the sling straps, which resulted in a sling loop coming off the hook and the resident falling, sustaining significant injuries including head lacerations and fractures. Staff interviews revealed uncertainty about how the incident occurred, and there was no evidence of equipment malfunction or that staff failed to follow the two-person transfer policy, but the behavioral risks were not specifically addressed in the care plan. In a separate incident, the same resident, who was at risk for falls and known to wander and enter other residents' rooms, fell from a wheelchair and sustained fractures to the tibia and fibula. The care plan included general fall prevention interventions and the use of a Roho cushion to minimize falls, but did not specify the level or timing of supervision required. On the day of the fall, the resident was found alone in another resident's room, having slid out of the wheelchair along with the cushion. Staff interviews indicated that the cushion may have contributed to the fall, especially since there were two cushions present and only one piece of non-slip material (dycem) was used, which was insufficient to prevent sliding. The resident's tendency to wander and require frequent supervision was known, but the care plan lacked clear directives on supervision frequency or intensity. The facility's policies required thorough investigation and reporting of accidents, as well as individualized fall prevention plans based on assessment. However, the incident reports for both accidents were not made available for review, and staff interviews indicated a lack of clarity regarding the circumstances of the incidents and the interventions in place at the time. There was no evidence that the facility had implemented specific behavioral or supervision interventions tailored to the resident's known risks during transfers or while using the wheelchair, contributing to the occurrence of both accidents and resulting injuries.