Resident Death Following Use of Inappropriate Transfer Device with Hoyer Lift
Penalty
Summary
A deficiency occurred when a resident was transferred using a Hoyer lift with a transfer sheet rather than an approved Hoyer sling, resulting in the resident being dropped and subsequently dying. The resident, who had recently been admitted with diagnoses including acute gastric ulcer with hemorrhage, unspecified diastolic heart failure, and morbid obesity, arrived at the facility on a stretcher with a transfer sheet underneath her. Two CNAs decided to use the transfer sheet already under the resident for the Hoyer lift transfer, despite it not being an approved or compatible sling for the lift. During the transfer, the straps of the transfer sheet snapped, causing the resident to fall onto the legs of the Hoyer lift. Immediate attempts at resuscitation were made, but the resident was pronounced deceased after EMS arrived and identified a DNR order. Interviews with staff revealed that the CNAs were familiar with using transfer sheets in place of Hoyer slings and had done so previously without incident. The CNAs did not verify whether the sling was approved for use with the Hoyer lift, and one CNA stated that she had used similar transfer slings in the past. The LPN on duty was not present in the room during the transfer but responded after hearing a yell and a thud, finding the resident on the floor. The transport driver who brought the resident to the facility expressed concern about using the transfer sheet for the Hoyer lift and advised against it, but the CNAs proceeded regardless. Further investigation found that staff training on the proper use of Hoyer lifts and slings was lacking, with some CNAs reporting they had not received hands-on training since their initial orientation. Facility policy regarding the exclusive use of facility-owned and approved slings was not consistently communicated or enforced among staff. Observations also indicated that Hoyer slings and transfer equipment were stored in a manner that could lead to confusion about which items were appropriate for use with the mechanical lift.