Resident Fall Due to Improper Hoyer Lift Use and Missing Safety Latches
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all transfers and activities of daily living due to multiple medical conditions including hemiplegia, diabetes, and a history of stroke, sustained a fall from a Hoyer lift during a transfer from bed to wheelchair. The incident happened during a one-person assisted transfer, despite facility policy and manufacturer guidelines requiring at least two staff members for safe operation of the mechanical lift. The resident was found on the floor with pain in the hip and knee, and later diagnosed with a fracture after being transferred to the hospital due to persistent, severe pain. Investigation revealed that the Hoyer lift used during the incident was missing safety latches on the cradle hooks, which are required by the manufacturer to prevent sling straps from slipping off. Staff interviews confirmed that the sling was not properly secured, with one of the straps not attached to the lift, and that the CNA operating the lift did not request assistance or verify the secure placement of all straps. The CNA involved admitted to not being familiar with the sling and noted that the absence of safety latches made it easier for straps to come off the hooks. Another CNA present at the time also failed to inspect the sling for proper placement, assuming the other staff member had done so. Observations and interviews further confirmed that both Hoyer lifts in the facility were missing some or all of the required safety latches, and that staff were not consistently following procedures to ensure equipment was in good working condition and that transfers were performed with adequate supervision. The facility's own policy and the manufacturer's instructions both require thorough inspection of the lift and sling, proper attachment of all straps, and the presence of two trained staff during transfers. These requirements were not met at the time of the incident, directly leading to the resident's fall and injury.