Failure to Honor Resident Choice Regarding Hoyer Sling Removal
Penalty
Summary
Facility staff failed to honor the choices of two cognitively intact residents regarding the removal of hoyer slings after transfers to their wheelchairs. Both residents, who required total assistance with transfers and had significant medical conditions such as heart failure, diabetes, stroke, hemiplegia, and chronic pain, were observed on multiple occasions sitting in their wheelchairs with the hoyer sling left underneath them. Both residents expressed discomfort and pain due to the sling being left in place, and one resident reported that staff told them the sling had to remain because there was not enough staff to remove and reapply it as needed. Interviews with nursing assistants revealed that slings were routinely left under residents for reasons of convenience and perceived safety, without consulting the residents about their preferences. One nursing assistant acknowledged the importance of removing the sling to prevent pressure ulcers, while another stated that residents were not asked about their preferences due to their compromised mobility. The Director of Nursing confirmed that slings should not be left under residents as they create pressure on the skin.