Failure to Follow Care Plan for Hoyer Lift Transfer Results in Resident Fall
Penalty
Summary
The facility failed to implement a comprehensive care plan intervention for a resident with Parkinson's Disease who required transfer using a Hoyer lift with four-person assistance, as specified in both the care plan and physician orders. Despite the care plan clearly stating that transfers should be performed by three CNAs and one nurse, the resident was transferred by only two CNAs. Both CNAs involved were aware of the four-person assist requirement, but one CNA stated that due to staff shortages, only two people had been assisting, while the other CNA believed the protocol had been changed to a two-person assist based on a prior meeting. During the transfer from bed to transport chair, the resident was seated in the chair when it flipped backward, resulting in a fall. The resident, who had moderately impaired cognition, complained of head pain but had no visible injuries and was sent to the emergency room for evaluation. The incident was classified as a staff violation of the care plan and physician orders, as the transfer was not conducted according to the individualized care plan requirements.