Resident Fall During Mechanical Lift Transfer Due to Improper Supervision and Equipment Attachment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and total dependence for transfers fell from a mechanical lift during a transfer. The resident, who was bedridden and required assistance for all activities of daily living, was being transferred by two Certified Nurse Aides (CNAs) using a Hoyer lift. The facility's fall prevention policy required a comprehensive approach to safety, including environmental adjustments and individualized interventions for residents at risk of falls. During the transfer, one CNA was preparing the resident's chair while the other CNA attached the Hoyer pad to the lift. As the resident was being lifted, they fell out of the Hoyer pad and struck their head on the leg of the lift. Upon investigation, it was found that one of the straps on the Hoyer pad had slipped or become detached during the lifting process, resulting in the resident's fall. Interviews with staff revealed inconsistencies in the sequence of actions, with one CNA stating they were not in position when the transfer began and the other indicating they had attached all the necessary clips. Further interviews with nursing staff and administration indicated that the Hoyer pad and equipment were intact, but the incident may have been caused by improper attachment or shifting of the resident during the transfer. The facility's investigation concluded that the strap may have come off due to the resident's movement or contact with the bed rail, but both CNAs believed they had followed proper procedures. The event demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided during the transfer process.