Failure to Follow Safe Hoyer Lift Procedures During Resident Transfer
Penalty
Summary
A deficiency occurred when staff failed to follow the facility's policy and procedure for the safe use of a Hoyer lift during a resident transfer. The resident involved had multiple significant injuries, including fractures to the ankle, fibula, breastbone, cervical and thoracic vertebrae, ribs, and a bed sore, and was non-weight bearing at the time. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to use the Hoyer lift to transfer the resident without the required assistance of a second staff member. During the transfer, one of the lift straps slipped out of place, causing the resident to fall onto the bed. The resident was assessed for injuries and none were found, but the incident left the resident feeling unsafe. Interviews with staff confirmed that facility policy required at least two staff members to operate the Hoyer lift. The CNA involved acknowledged being aware of this requirement but proceeded to use the lift alone. Another CNA witnessed the incident and reported that the resident requested not to be lifted again, but observed the same CNA attempt another lift with the resident. The facility's policy, as well as staff interviews, confirmed that the use of the Hoyer lift by a single staff member was not permitted and constituted a failure to provide adequate supervision and accident prevention.