Failure to Ensure Safe Transfer and Documentation After Hoyer Lift Fall
Penalty
Summary
A resident with a history of acute respiratory failure and impaired physical mobility, who was assessed as cognitively intact, was involved in a transfer incident using a Hoyer lift. The care plan specified that two staff members and a Hoyer lift were required for transfers. During a transfer performed by a CNA and the Director of Nursing, the sling being used—brought with the resident upon readmission from the hospital—ripped, causing the resident to fall to the floor and strike her head. The resident was subsequently sent to the hospital, where no intracranial injuries or fractures were found. The incident was not documented in the electronic medical record, and there was uncertainty among staff regarding whether an incident report or progress note was completed. The facility's policy required the use of appropriate techniques and equipment to ensure resident safety, but the use of a potentially unsuitable sling and lack of documentation following the incident indicated a failure to follow established procedures. The administrator at the time of the survey was unable to locate any records or documentation related to the event.