Failure to Follow Hoyer Lift Protocol Results in Resident Fall and Multiple Fractures
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to follow a resident's comprehensive care plan and the facility's Mechanical Lift/Hoyer Lift Safety procedure during a transfer from a wheelchair to a bed. The care plan specified that the resident, who had diagnoses including chronic respiratory failure with ventilator dependence, cerebral palsy, paraplegia, and an anxiety disorder, required a two-person assist for transfers using a Hoyer lift. Despite being trained and having signed an attestation acknowledging the two-person requirement, the CNA attempted the transfer alone. During the transfer, the resident slipped out of the Hoyer sling and fell to the floor. The CNA reported using her body to guide the resident's fall, but the resident's head struck the floor, resulting in a hematoma above the left eyebrow. The incident was witnessed after the fact by the Respiratory Manager, who assisted in repositioning the resident onto the Hoyer sling and transferring the resident back to bed. The resident later exhibited neurological changes and was transported to the hospital, where multiple fractures were confirmed. Documentation and interviews revealed that staff, including an RN and another CNA, had offered assistance to the CNA prior to the transfer, but the CNA did not request help. The facility's policies and the resident's care plan were not followed, as the transfer was performed by a single staff member. The incident was reported to the state health department after the extent of the resident's injuries was confirmed.