Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to provide sufficient supervision and follow appropriate safety procedures during the use of a Hoyer lift for a resident who required total assistance with activities of daily living. The facility's policy mandated that two staff members be present when using a mechanical lift, and the resident's care plan specifically directed the use of a Hoyer lift with two staff during transfers. Despite these requirements, a single staff member attempted to transfer the resident alone, resulting in the resident falling from the lift. The incident involved a resident with end-stage renal disease, dependence on dialysis, chronic pain, and impaired mobility, who was cognitively intact and required total assistance. During the transfer, the staff member did not properly fasten the sling, and the resident fell onto the iron bars of the lift, sustaining a left femoral condylar fracture and a left clavicle fracture. The resident was in significant pain and distress following the fall and was subsequently sent to the emergency department for evaluation. Interviews and record reviews confirmed that the staff member did not request or wait for assistance from another staff member, as required by facility policy. Other staff and management acknowledged that the policy was not followed, and the equipment was found to be in proper working order. The deficiency was attributed to the staff member's failure to adhere to established safety protocols during the transfer process.