Single-Staff Hoyer Lift Transfer Performed Against Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a Hoyer lift without the required assistance of a second staff member. The resident, an elderly female with muscle weakness and incontinence, required extensive assistance with activities of daily living and was cognitively intact. According to the resident's care plan and the facility's policy, two staff members were required to operate the Hoyer lift to ensure safety during transfers. On the day of the incident, the resident was observed in bed with the Hoyer lift still positioned over her, and only one CNA was present in the room. Interviews with the resident and staff confirmed that the transfer was performed by a single CNA, despite the facility's policy and recent in-service training mandating two-person operation of the lift. The CNA involved acknowledged she was unable to find another staff member to assist and proceeded with the transfer alone. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both confirmed the two-person requirement for Hoyer lift use, and the facility's policy reflected this standard. Documentation and interviews indicated that this practice of single-staff transfers with the Hoyer lift had occurred on multiple occasions.