Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on two staff members and a mechanical (Hoyer) sling lift for all transfers, was transferred by only one Certified Nursing Assistant (CNA) using the lift. During this unsupervised transfer, the lift tipped over, causing the resident to fall to the floor and sustain a right hip fracture. The resident was subsequently transferred to the hospital for treatment and did not return to the facility after discharge. The resident had a history of multiple rib fractures, syncope, and anxiety disorder, and was assessed as having an activity of daily living (ADL) deficit, requiring a mechanical lift for transfers. The care plan and facility policy both specified that at least two staff members were required for safe use of the mechanical lift. The manufacturer's guidelines also recommended two assistants for all lifting and transferring procedures. Despite these requirements, the CNA performed the transfer alone, without requesting assistance from other available staff. Interviews with staff confirmed that the CNA did not ask for help before attempting the transfer. Other CNAs and the nurse on duty were only called to assist after the resident had already fallen. The facility's investigation verified that the transfer was not conducted according to policy or manufacturer instructions, directly resulting in the resident's injury.