Resident Fall and Injury Due to Use of Damaged Hoyer Sling During Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical diagnoses, including epilepsy and a right femur fixation device, was not kept free from accident hazards during a hoyer lift transfer. The resident required a three-person assist for all transfers due to his use of a geriatric chair, as documented in his care plan. During a transfer from his geri chair back to bed, the hoyer sling tore, causing the resident to fall to the floor and sustain a right hip fracture. Staff interviews revealed that the facility's protocol required checking the integrity of the hoyer sling before use and ensuring the correct size and type of sling was used for each resident. Multiple CNAs described their process for inspecting slings, including checking for fraying, tears, and weakened seams. One CNA reported noticing fraying and unusual noises from the sling during a previous transfer and stated that these concerns were reported to a team lead. However, the sling was not removed from service and was used again, resulting in the incident. The Director of Nursing confirmed that the expectation was for staff to thoroughly check the integrity of the sling and to remove any with signs of wear or damage. The investigation determined that the root cause of the incident was the use of a hoyer sling with impaired integrity, which had been identified by staff prior to the accident but not acted upon. The clinical record did not show any orders or assessments related to the accident at the time of the incident.