Failure to Ensure Safe Resident Transfers Using Mechanical Lifts
Penalty
Summary
The facility failed to ensure safe transfer practices for residents requiring manual and mechanical Hoyer lifts, as evidenced by multiple incidents involving three residents. One resident with severe dementia and agitation was observed being transferred by a hospice aide using a Hoyer lift without the required assistance of a second staff member, contrary to the facility's policy mandating two staff for such transfers. The aide confirmed performing the transfer alone, and the policy review supported the need for two staff to ensure safety. Another resident with severe obesity and cognitive intactness reported being left suspended in the air during transfers due to mechanical lift or battery failures. Staff interviews revealed that mechanical lifts frequently lost power during transfers, requiring the use of emergency releases or battery changes mid-transfer. There was no established protocol for charging lift batteries, and staff confirmed that lifts often began beeping and slowed down during use. During an observed transfer, the lift's metal attachment nearly struck the resident's head after being unhooked, and staff acknowledged this was not an uncommon occurrence. A third resident, dependent on staff for transfers due to dementia and muscle weakness, was observed being transferred with the mechanical lift's legs in the closed position throughout the process, contrary to manufacturer instructions and facility policy, which require the legs to be fully open for stability except when maneuvering under a bed. Staff interviews confirmed awareness of the correct procedure but did not follow it during the observed transfer. These findings demonstrate a pattern of non-compliance with established safety protocols for resident transfers using mechanical lifts.