Failure to Implement Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to implement appropriate transfer interventions for a resident who was assessed as requiring a mechanical lift (hoyer) with two staff for transfers. Despite repeated recommendations and notifications from physical therapy staff, including documentation on multiple occasions that the resident was dependent for transfers and unable to bear weight through the lower extremities, nursing staff continued to use unsafe transfer techniques such as a one-person stand-pivot and bear hugging. These methods were explicitly identified as unsafe for both the resident and staff, and the need for a mechanical lift was communicated verbally and in writing to nursing staff and the unit manager. On one occasion, a licensed nursing assistant transferred the resident using a stand-pivot technique, during which the resident expressed pain. The following day, the resident was kept in bed due to complaints of pain and was observed holding their left leg. Subsequent nursing assessment revealed swelling, redness, and tenderness in the left lower extremity, and an x-ray confirmed a minimally displaced spiral fracture of the mid to distal tibia. The resident's care plan had been updated to require a two-person hoyer transfer, but this intervention was not followed, resulting in injury.