Failure to Use Hoyer Lift During Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident from bed to wheelchair using a stand and pivot method instead of the Hoyer lift as specified in the resident's comprehensive care plan. The resident was care planned as totally dependent for transfers and required the use of a Hoyer lift with two-person assistance due to significant physical limitations, including generalized muscle weakness, muscle wasting and atrophy, and impaired range of motion in both upper extremities. The CNA did not utilize the Hoyer lift during the transfer, resulting in the resident hitting her right arm on the wheelchair armrest and experiencing acute pain. The resident's medical record indicated a history of cerebral infarction, rheumatoid arthritis, and generalized osteoarthritis, and she was admitted to hospice care. The care plan interventions specifically included the use of a Hoyer lift for all transfers, and this requirement was documented in the resident's chart and typically indicated by a sign over the resident's bed. On the day of the incident, the CNA was not aware of the resident's transfer requirements and did not check the care plan or observe a sign over the bed. The CNA later reported not knowing how to look up transfer abilities until after the incident. Multiple staff interviews confirmed that the resident was dependent on staff for transfers and that the standard practice was to use a Hoyer lift, with signage over the bed to indicate this need. The incident resulted in the resident sustaining an acute complex impacted fracture of the right humeral neck, requiring emergency evaluation and treatment. The CNA involved had received facility orientation and had worked at the facility on several occasions prior to the incident, but failed to follow the care plan during the transfer.