Failure to Use Required Hoyer Lift Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who required a Hoyer lift with two-person assistance for all transfers due to impaired mobility, was not transferred according to their care plan. The resident had a documented need for maximal assistance with transfers and was unable to ambulate. Despite these requirements, a Geriatric Nursing Assistant (GNA) failed to identify and follow the resident's transfer status, attempting to assist the resident without a Hoyer lift or a second staff member. The GNA did not consult the resident's medical chart or seek clarification from nursing staff regarding the appropriate transfer method. During the transfer, the resident attempted to stand and move independently, resulting in a fall and a displaced fracture of the distal femur, as confirmed by radiology. Interviews and documentation revealed that the GNA was present but did not intervene to prevent the resident from transferring unsafely, nor did they seek additional help. The resident reported attempting to transfer from a wheelchair to bed, referencing recent therapy sessions but ultimately being unable to move their feet and falling. The Director of Nursing and Director of Rehabilitation both confirmed that the resident required a Hoyer lift with two-person assistance at the time of the incident, and that the staff member failed to follow established protocols for safe transfers.