Failure to Follow Two-Person Hoyer Lift Policy During Resident Transfer
Penalty
Summary
A certified nursing assistant (CNA) was observed transferring a resident who required a Hoyer lift for all transfers without the assistance of a second staff member, contrary to facility policy and training. The resident had diagnoses of type 2 diabetes and muscle weakness, and was care planned as dependent on staff for all transfers, including bed, chair, toilet, and shower/tub. Facility documentation, including the facility assessment and policy, specified that two staff members are required for all mechanical lift transfers to ensure safety. Multiple staff interviews confirmed that the expectation and training were for two staff to be present during Hoyer lift use. Despite this, the CNA proceeded with the transfer alone, acknowledging in a subsequent interview that they were aware of the requirement for two staff but did not have a second person present during the observed transfer. Other staff, including another CNA, an LPN, and the Director of Nursing, all confirmed the two-person policy and recent training on this requirement. The facility's policy explicitly stated that two healthcare personnel must be present for mechanical lift transfers, but this was not followed during the incident.