Failure to Ensure Safe Hoyer Lift Transfer Resulting in Resident Injury
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure resident safety during a Hoyer lift transfer, resulting in harm to a resident with dementia and anxiety. During the transfer, one of the Hoyer lift legs became stuck under a closet door, which caused a sling strap webbing loop to slip off one of the lift's six-point loop connections. This improper transfer led to the resident falling out of the Hoyer lift and sustaining left superior and inferior pubic fractures. The incident occurred because the CNAs did not move furniture or adequately plan the transfer process, as required by the Hoyer lift user manual. The lack of proper preparation and failure to ensure a clear path for the lift directly contributed to the accident and subsequent injury to the resident.