Resident Fall During Mechanical Lift Transfer Due to Staff Training and Supervision Lapses
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls and dependent on staff for transfers, was not safely transferred using a mechanical Hoyer lift. The resident, who had multiple diagnoses including dementia, catatonic disorder, and impaired mobility, had a documented history of recent falls. On the day of the incident, the resident was being transferred with the assistance of a CNA and an LPN. During the transfer, the front left hook of the Hoyer lift became unfastened, causing the resident to fall from the lift and hit her head on the floor. The resident was sent to the emergency room and returned with no noted injuries. Interviews revealed that the CNA believed the resident may have attempted to move the Hoyer strap and could not recall her last training on the lift. The LPN, who was assisting, did not witness the hook check as she was gathering supplies at the time. After the fall, the LPN checked the equipment and found all straps in working order. Both staff members indicated a lack of recent or initial training on the Hoyer lift. Facility policy required two staff for mechanical lift transfers and annual competency documentation, but this was not followed, contributing to the incident.