Failure to Prevent Injury During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from avoidable accidents during transfers with a mechanical (Hoyer) lift. The resident involved had multiple diagnoses, including sequelae of cerebral infarction, hemiplegia, congestive heart failure, and severely impaired cognition, and was dependent on staff for all activities of daily living, including transfers. The care plan and physician orders specified that transfers were to be performed using a Hoyer lift with two-person assistance. During a transfer, staff failed to prevent the Hoyer lift sling bar from hitting the resident's face, resulting in bruising and swelling to the lower left side of the mouth, lip, and chin. Staff interviews confirmed that two CNAs were present during the transfer and that the injury occurred when the sling bar swung back and struck the resident. The facility's policy on using a mechanical lifting machine required staff to ensure that the sling bar does not hit the resident during transfers. The incident report and staff interviews verified that this policy was not followed, leading to the resident's injury. The deficiency was identified during a complaint investigation and was based on medical record review, incident report, staff interviews, and policy review.