Failure to Follow Two-Person Hoyer Lift Transfer Policy Resulting in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and the resident's care plan requiring two staff members to assist with all Hoyer lift transfers. A resident with mild dementia, anxiety, and left-side hemiplegia following a stroke, who was dependent on staff for all transfers, sustained a right ankle fracture of unknown origin. The resident reported pain and swelling in the right ankle after a transfer, and upon assessment, a hairline fracture was identified. The resident stated that a CNA transferred her without using the correct lift and dropped her, although the CNA denied dropping or injuring the resident. Video evidence confirmed that a CNA performed a Hoyer lift transfer alone the evening before the injury, and another CNA also admitted to transferring the resident with the Hoyer lift without a second staff member present. The facility's investigation found that the required two-person assistance for Hoyer lift transfers was not followed by staff on multiple occasions. The failure to adhere to established transfer protocols and the resident's care plan resulted in the resident sustaining a fracture from an unknown source. The incident was determined to be past non-compliance after review of the events and staff interviews.