Failure to Provide Required Two-Person Assistance During Mechanical Lift Transfer Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a Certified Nursing Assistant (CNA) failed to provide two-person physical assistance while transferring a resident using a Hoyer lift, contrary to the facility's policy and recent in-service training. The resident, who had morbid obesity and acute respiratory failure with hypoxia, was fully dependent on staff for activities of daily living, including transfers. On the day of the incident, the CNA attempted to transfer the resident alone from bed to a shower gurney using the Hoyer lift, despite knowing that two staff were required for such transfers. During the transfer, the Hoyer lift became unstable and tilted, causing the resident to fall to the floor. The resident's head and neck struck the floor, and the right lower leg was pinned between the shower gurney and the lift. The incident resulted in visible injuries, including a bump on the back of the head, bruising and swelling of the right lower leg, and a bruised finger. The resident was subsequently transferred to a hospital for evaluation of possible head injury, leg trauma, and other complications, especially given the use of blood thinners. Interviews with the resident, staff, and review of records confirmed that only one CNA was present during the transfer, and the CNA did not request assistance due to short staffing. Both the Director of Nursing and Director of Staff Development confirmed that facility policy and training required two staff for Hoyer lift transfers to ensure safety. The CNA involved acknowledged awareness of this requirement but proceeded alone due to perceived staffing shortages.