Failure to Ensure Two-Person Assist During Hoyer Lift Transfer Results in Resident Fall
Penalty
Summary
Nursing staff failed to follow facility policy and procedure regarding the use of a Hoyer lift for transferring a resident who required total assistance with activities of daily living. The facility's policy and in-service training required two-person physical assistance when using a Hoyer lift, and staff were trained and had acknowledged this requirement. Despite this, a certified nursing assistant (CNA) attempted to transfer a resident alone using the Hoyer lift, citing short staffing as the reason for not obtaining a second staff member. The resident involved had a history of morbid obesity and acute respiratory failure with hypoxia, and was dependent on staff for all transfers and personal care. During the transfer, the resident was suspended in the Hoyer lift by the CNA alone, which resulted in the lift tilting and the resident falling to the floor. The resident's head and neck struck the floor, and the right lower leg became pinned between the shower gurney and the lift. The incident was witnessed by another staff member who responded to calls for help and observed the aftermath, including the resident's injuries and the malfunction of the lift. Documentation and interviews confirmed that the CNA had attended the required in-service training and was aware of the two-person assist policy. Both the Director of Staff Development and the Director of Nursing stated that two staff are required for safe operation of the Hoyer lift and that failure to follow this protocol could result in injury. The facility's policy emphasized the need for sufficient and competent staffing to meet resident needs, but this was not adhered to during the incident, directly leading to the resident's fall and injuries.