Failure to Follow Safe Mechanical Lift Practices Resulting in Resident Death
Penalty
Summary
Facility staff failed to protect a resident from neglect by not following safe lifting practices during transfers with a mechanical lift. Multiple staff interviews revealed that, despite being trained to use two staff members for mechanical lifts, the facility had adopted a practice of using only one staff member for these transfers. This change was attributed to reduced staffing levels following administrative decisions to decrease staff hours. The resident's care plan specifically required two staff members to assist with transfers using a Hoyer lift, but this directive was not followed. As a result of this failure, the resident, who was totally dependent on staff for transfers, fell from the Hoyer lift. The incident resulted in the resident being found on the floor with significant injuries, including a subdural hematoma, C2 cervical fracture, and a forehead laceration. The resident was transported to the hospital and died three days later. The cause of death was listed as a subdural hematoma due to a fall from a Hoyer lift.