Resident Injury During Hoyer Lift Transfer Due to Unsecured Strap
Penalty
Summary
A deficiency occurred when a resident sustained a 3 cm laceration to the posterior scalp during a transfer using a Hoyer lift. The incident took place as two CNAs were transferring the resident from bed to a Broda chair. The resident, who had diagnoses including obsessive compulsive disorder, anemia, restlessness, agitation, and abnormal posture, fell when one of the Hoyer lift straps became unhooked during the transfer. The resident struck the back of his head on the floor and was subsequently sent to the emergency room, where the wound was closed with three staples before returning to the facility. Interviews and facility statements revealed that both CNAs attached the Hoyer lift straps but did not verify together that all straps were secure before initiating the transfer. One CNA reported that the strap on the resident's left side closest to his head was not securely fastened and fell off, resulting in the resident falling from the lift. Subsequent interviews with QMAs and the interim DON confirmed that the Hoyer lift and sling were in proper working order, and that standard procedure required all four straps to be secured and rechecked by two staff members prior to use. The failure to ensure all straps were properly secured directly led to the resident's fall and injury.