Incorrect Hoyer Sling Size Used for Dependent Resident
Penalty
Summary
Staff failed to ensure the correct size Hoyer lift sling was used for a resident with right-sided paralysis, contracture, neglect syndrome, and dementia. The resident's care plan and medical record specified the use of a medium (purple) sling for all mechanical lift transfers, in accordance with the manufacturer's guidelines and the resident's weight. However, during observation, the resident was found seated in a broda chair with a green (large) sling in use, contrary to the care plan instructions. The Certified Nursing Assistant (CNA) involved confirmed the care plan required a medium sling and expressed surprise at the error, despite recent education and skill checks provided to staff. The facility's policy mandates that resident handling and transfers be performed according to each resident's individual plan of care to minimize injury risk. The deficiency was identified when the surveyor observed the incorrect sling in use and verified the care plan documentation with the CNA. The Nursing Home Administrator confirmed that all other residents requiring Hoyer lifts were checked and found to have the correct sling size, with the exception of this resident.