Failure to Use Two-Person Assist During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to use a required two-person assist during a Hoyer Lift transfer for a resident with significant cognitive and physical impairments. The resident, who had diagnoses including metabolic encephalopathy, vascular dementia, and cerebral infarction, was dependent on staff for all transfers and unable to make decisions or support himself. Despite care plan interventions and physical therapy recommendations indicating the need for full assistance, a certified nursing assistant (CNA) transferred the resident from a wheelchair to a bed using the Hoyer Lift without a second staff member present. Multiple interviews confirmed that facility policy, the resident's care plan, and the manufacturer's guidelines all required two staff members for Hoyer Lift transfers to ensure safety. The CNA, as well as other staff including an LVN, RN, DON, and Director of Rehab, acknowledged that a two-person assist was necessary for this resident due to his cognitive and physical limitations. The incident was directly observed and reported by the responsible party, and documentation supported that the resident was fully dependent and at risk during transfers.
Plan Of Correction
Corrective Action: Res1 is currently in the hospital. RN will assess Res 1 regarding transfer assistance needs upon return. On 7/31/25, the DON/DSD provided CNA1 1:1 service/disciplinary action regarding the need to exercise clinical judgement when operating a Hoyer lift with another staff. How to Identify Potentially Affected: On 7/29/25, the charge nurses checked other residents requiring Hoyer lifts for transfers to ensure the staff is operating it safely, with another staff assisting as needed. No similar issues identified. Systematic Change: On 7/30-31, 2025, the DSD/Designee (Director of Staff Developer) in-serviced the licensed nurses and licensed nurses on the facility's policy on operating Hoyer lifts with additional staff based on staff's clinical judgment, to ensure resident's safety. The facility will continue to have visual identifiers for the use of Hoyer lifts to alert CNAs and Licensed nurses. The DSD will complete the CNAs' skills competency on how to safely operate the Hoyer lift upon hire, annually, and as needed. MONITORING: The DON/Supervisors/Charge Nurses will monitor compliance with proper use of Hoyer lifts through routine rounds. The facility will conduct a QA study on staff compliance to the use of Hoyer lifts in the next 30 days or until acceptable compliance is achieved. If lack of compliance is identified, revisions will be made as needed. Trends and findings will be reported to the QA committee for further recommendations. Completion date: 8/10/25