Resident Injured During Unsafe Hoyer Lift Transfer Due to Air Mattress Obstruction
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who was dependent on staff for all transfers and required the use of a Hoyer lift. The resident, who had diagnoses including Parkinson's disease with dyskinesia, generalized muscle weakness, and chronic systolic heart failure, was being transferred from a wheelchair to bed using a Hoyer lift by two CNAs. The resident's care plan specified the use of a Hoyer lift with two staff and an air mattress with bolsters was in place on the bed as a pressure relief intervention. During the transfer, the Hoyer lift did not clear the raised bolsters of the air mattress. As the staff maneuvered the resident onto the bed, the lift tipped and the top-heavy part struck the resident on the head, resulting in a laceration and concussion. The incident was witnessed by the two CNAs performing the transfer, and the nurse on duty was called to assess the resident immediately after the injury occurred. The resident was transported to the emergency department, where he received six staples to close the wound and was diagnosed with a concussion. Interviews with staff revealed that the air mattress's height and bolsters interfered with the safe operation of the Hoyer lift, contributing to the tipping incident. The manufacturer's guidelines for the Hoyer lift warned of the risk of tipping and emphasized the need to keep the base widened for stability. The facility's policy required at least two staff for mechanical lift transfers and for staff to ensure resident safety and security during transfers. Despite these guidelines and policies, the transfer was not completed safely, resulting in actual harm to the resident.