Failure to Use Hoyer Lift for Dependent Resident Transfer
Penalty
Summary
Nursing staff failed to follow the care plan for a resident who was assessed as requiring a Hoyer lift for all transfers. The resident, who had diagnoses including peripheral vascular disease, lumbar spondylopathy, vascular dementia, and anxiety, was documented as totally dependent on staff for transfers and at risk for falls. The care plan, therapy assessments, and facility policies all specified the use of a Hoyer lift with two-person assistance for transfers, and the resident was listed as a total lift on the facility's lift list. On the morning in question, the resident was observed in a wheelchair without a Hoyer lift pad, which is typically left in place after a mechanical lift transfer. Multiple staff interviews confirmed that the resident had been transferred from bed to wheelchair without the use of a Hoyer lift. The agency CNA assigned to the resident admitted to using a stand and pivot transfer method instead of the required Hoyer lift, despite being trained on the facility's procedures and having access to the resident's care plan in the electronic system. The CNA stated that the resident was able to assist with the transfer and that a Hoyer lift pad was not available in the room at the time. Supervisory staff, including the CNA supervisor, RN supervisor, and Director of Rehabilitation, all confirmed that the resident was care planned for Hoyer lift transfers and that the correct procedure was not followed. The agency CNA's personnel record showed she had completed facility orientation and acknowledged her responsibility to follow the care plan and report any concerns to management. The failure to use the Hoyer lift as required by the care plan and facility policy constituted neglect, as it did not provide the necessary services to avoid potential physical harm or distress to the resident.