Failure to Follow Two-Person Hoyer Transfer Protocol Results in Resident Injury
Penalty
Summary
Facility staff failed to follow the established plan of care for a dependent resident with quadriplegia and an above-the-knee amputation, resulting in significant injury during a transfer. The resident, who was totally dependent for all activities of daily living and required a Hoyer lift with assistance from two staff members for transfers, was instead transferred by a single geriatric nursing assistant (GNA). The GNA used the resident's own sling but did not have a second staff member present, as required by the care plan. During the transfer from bed to chair, the wheel of the Hoyer lift struck the end of the bed, causing the resident to slip through the sling and fall to the floor, landing on the buttocks. Following the fall, the resident complained of back pain and was subsequently transferred to the hospital, where imaging revealed bilateral sacral fractures and an L2 compression fracture. The resident was alert but not at full baseline, likely due to pain and lack of sleep after spending the night in the emergency room. Staff interviews confirmed that the GNA was working alone at the time of the transfer, despite the care plan's requirement for two-person assistance. Other staff members reported that short staffing was common, and it was not unusual for GNAs to perform Hoyer transfers alone when the facility was understaffed. Documentation and interviews indicated that the unit was short-staffed on the day of the incident, with GNAs assigned to multiple units and responsible for a high number of residents, many of whom required total care. The nurse on duty and other GNAs corroborated that the transfer was performed by one person, and that this practice had occurred previously due to staffing shortages. The failure to adhere to the resident's care plan and provide adequate supervision during the transfer directly resulted in the resident's injuries.