Failure to Ensure Two-Person Assistance During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when a resident who requires total assistance for transfers, as documented in their care plan and Minimum Data Set (MDS), was transferred using a Hoyer lift by only one Certified Nursing Assistant (CNA) instead of the required two staff members. The facility's policy and the resident's care plan both specify that all mechanical lift transfers must be performed with two staff to ensure safety. The resident, who has multiple diagnoses including spina bifida, diabetes mellitus, asthma, chronic heart failure, and a history of falls, reported to the surveyor that sometimes only one CNA assists with Hoyer lift transfers, particularly during the PM shift. During interviews, a CNA confirmed that due to staffing shortages, he sometimes performs Hoyer lift transfers alone, including with this resident, despite knowing the policy requires two staff. Both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that they expect staff to follow the facility's policy and resident care plans, which mandate two staff for Hoyer lift transfers. The failure to consistently provide adequate supervision and follow established transfer protocols led to the deficiency.