Improper Hoyer Lift Use Results in Resident Fall and Injury
Penalty
Summary
Staff failed to operate a Hoyer lift in a safe manner during a transfer, resulting in a resident falling and sustaining injuries. The incident occurred when a CNA and an RN attempted to transfer a resident with severe cognitive impairment and total dependence for transfers using a Hoyer lift. During the process, the lift became stuck, and staff forcefully pulled and pushed the equipment, leading to the disconnection of the transfer sling strap and causing the resident to fall to the floor. The resident involved had a history of chronic kidney disease, hypertensive heart disease, and venous insufficiency, and was identified as high risk for falls, requiring the use of assistive devices for transfers. The care plan specified the use of a Hoyer lift and staff assistance for all transfers. Despite these interventions, the staff did not ensure that the sling straps were properly secured before attempting the transfer, and did not follow safe transfer procedures when the lift became jammed. As a result of the fall, the resident sustained a laceration above the right eyebrow that required sutures and a laceration to the right wrist that required wound care. Staff statements and medical records confirmed that the improper handling of the Hoyer lift and failure to secure the sling straps directly led to the resident's injuries.