Failure to Follow Two-Person Hoyer Lift Transfer Protocol
Penalty
Summary
Staff failed to consistently implement and follow a resident's comprehensive care plan, which required two staff members to assist with all Hoyer lift transfers. Despite clear documentation in the resident's care plan and care card, as well as facility policy mandating two-person assistance for mechanical lift transfers, two CNAs independently transferred the resident using the Hoyer lift without assistance on multiple occasions. Both CNAs acknowledged awareness of the policy and the resident's care requirements but proceeded to perform transfers alone. The resident involved had diagnoses including dementia, anxiety, and adult failure to thrive, and was assessed as needing full mechanical lift transfers with two-person assistance. The deficiency was identified through review of records, interviews with the CNAs, and confirmation from facility leadership that the required procedures were not followed. The failure to adhere to the care plan and facility policy was confirmed during interviews and documentation review.