Improper Use of Hoyer Lift Without Required Staff Assistance
Penalty
Summary
A certified nursing assistant (CNA) transferred a resident from bed to wheelchair using a Hoyer lift without the required assistance of a second staff member. The resident had a history of muscle weakness, traumatic brain injury, and severely impaired cognition, and was documented as dependent on two or more helpers for transfers. The CNA acknowledged operating the Hoyer lift alone, stating it was a mistake and recognizing the risk of dropping the resident without support from another staff member. The resident's care plan indicated a self-care performance deficit, impaired balance, and dependence on staff for transfers. The facility's policy and procedure, as confirmed by the Director of Nursing (DON), required at least two nursing assistants to safely transfer a resident using a mechanical lift. The DON also confirmed that transferring the resident alone increased the risk for falls. The deficiency was identified through observation, interview, and record review.