Failure to Lock Bed and Hoyer Lift During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNA2 and CNA3) failed to lock both the bed and the Hoyer lift before placing the sling under a resident with a history of hemiplegia, hemiparesis, cerebral infarction, aphasia, and previous falls. The resident's care plan specifically required a safe environment with bed wheels locked and assistance with all transfers due to impaired gait, balance, and mobility. During the observed transfer, neither the bed nor the Hoyer lift was locked, contrary to the care plan and facility policy. Interviews with the involved CNAs, a Licensed Vocational Nurse, and a Registered Nurse confirmed that both the bed and the Hoyer lift should have been locked to ensure safety and prevent accidents. The facility's policy on using mechanical lifts also required staff to ensure the lift was stable and locked before use. The failure to follow these procedures was directly observed and acknowledged by staff, representing a lapse in implementing required safety measures for the resident.