Resident Injury Due to Improper Mechanical Lift Use During Transfer
Penalty
Summary
A deficiency occurred when staff failed to properly transfer a resident who required total assistance with a mechanical lift due to dementia and extensive ADL self-care deficits. During a transfer from bed to a Broda chair using a mechanical (hoyer) lift, the staff did not open the legs of the lift as required by facility policy, resulting in the lift tipping over sideways while the resident was in the sling. The resident fell to the floor, sustaining a laceration to the bridge of the nose, an 8x7 cm hematoma with a 0.5 cm laceration on the left side of the head, and a 0.5 cm laceration on the back of the head. The resident was alert, able to answer questions, and did not complain of pain or discomfort following the incident. Interviews with staff confirmed that the hoyer lift was operated with the legs in the closed position during the transfer, and the attempt to open the legs while the resident was suspended caused the lift to become unbalanced and fall. Facility policy required that the base legs of the lift be locked in the maximum open position for stability and resident safety during all transfers. Documentation and staff statements consistently indicated that this policy was not followed at the time of the incident, directly leading to the resident's injuries.