Failure to Provide Required Assistance During Hoyer Lift Transfer Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a hospice nurse aide (HNA) performed a Hoyer lift transfer of a resident without the required assistance of a second staff member, contrary to physician orders and facility policy. The resident, who had multiple complex medical conditions including multiple myeloma, paraplegia, and severe muscle weakness, required total assistance for transfers and had a specific order for two-person Hoyer lift transfers. Despite this, the HNA proceeded alone, did not activate the call light for help, and expressed impatience about waiting for additional staff. During the transfer, the resident expressed fear and questioned whether two people were needed, but the HNA insisted on proceeding alone. The resident attempted to stabilize herself by grabbing a bed grab bar, and during the maneuver, a loud popping sound was heard, after which the resident's right arm became limp and she immediately reported it felt broken. The HNA dismissed the resident's complaints as being dramatic and did not seek immediate assistance or report the injury to nursing staff. The resident was left in pain and distress, with her arm visibly deformed and nonfunctional. Subsequent assessment by facility staff revealed significant swelling and discoloration of the resident's right arm, and an x-ray confirmed a displaced, separated, and overriding oblique fracture of the midshaft of the right humerus. The incident was captured on video, which showed the HNA performing the transfer alone, failing to control the resident's movement in the lift, and not responding appropriately to the resident's pain or injury. The HNA later admitted to not following policy and not requesting help, citing impatience and a belief that she could manage alone.