Failure to Provide Adequate Supervision During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with muscle weakness, chronic venous hypertension, and arthritis in the left knee experienced pain during a transfer using a Hoyer lift. The incident happened when a Certified Nurse Assistant (CNA) weighed the resident using the lift without a second staff member present, contrary to facility policy and staff training, which require two people for safe operation of the mechanical lift. The resident reported that the sling was not applied correctly and the metal part of the lift struck his left knee, causing pain. Interviews with staff, including the Restorative Nurse Assistants (RNAs), Director of Staff Development (DSD), and Director of Nursing (DON), confirmed that the expectation and policy is for two staff members to be present when using a Hoyer lift. The CNA involved in the incident proceeded alone because other CNAs were on break, despite being aware of the two-person requirement. Review of the facility's policy further supported that at least two nursing assistants are needed to safely move a resident with a mechanical lift.