Resident Fall Due to Incorrect Sling Use During Hoyer Lift Transfer
Penalty
Summary
Staff failed to provide adequate assistance to prevent accidents when two CNAs used a Hoyer lift to transfer a resident but did not use the correct size or type of sling. During the transfer, the sling straps broke while the resident was suspended in mid-air, resulting in the resident falling to the ground and sustaining a laceration to the back of the head. The resident required hospital evaluation and sutures for the injury. The resident involved had severe cognitive impairment, was dependent on staff for all transfers, and had diagnoses including stroke with right-sided hemiplegia, seizures, non-Alzheimer's dementia, and malnutrition. The care plan specified the need for two staff members to assist with Hoyer lift transfers and the use of a large sling, as ordered by the physician. Despite these requirements, staff used a pad that was not the correct Hoyer sling, and it was later determined that a slide transfer pad, which resembled a Hoyer pad but was not designed for use with the lift, was used instead. This led to the failure of the straps and the resident's fall. Interviews and record reviews revealed inconsistencies in staff accounts regarding who was present during the incident, but it was confirmed that the wrong pad was used and that the staff did not follow the resident's care plan or the facility's policy for mechanical lift transfers. The incident occurred at the end of a shift, and the resident was found on the floor with a head laceration. The facility's investigation concluded that the use of the incorrect pad directly contributed to the accident.