Resident Fall Due to Improper Hoyer Lift Attachment
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident was free from accident hazards and did not provide adequate supervision during a transfer using a Hoyer lift. The incident involved a resident with significant medical needs, including anemia, chronic respiratory failure, and a history of cerebrovascular accident, who was fully dependent on staff for mobility. During a transfer to weigh the resident, the attachment holding the bar and scale of the Hoyer lift became disconnected, resulting in the resident falling to the floor and sustaining a head laceration that required sutures and ICU observation. Record reviews and interviews revealed that both the LVN and CNA involved in the transfer believed the attachment was secure before lifting the resident. However, as the resident was being moved away from the bed to obtain an accurate weight, the attachment suddenly disconnected. The maintenance staff later demonstrated that the lift's interlocking hooks and safety latch were functioning properly and found no mechanical defects or wear on the equipment. The facility's investigation concluded that the primary cause of the incident was the separation of the attaching C clasp on the scale portion of the Hoyer lift from the C clasp of the lifting strap, likely due to improper securing of the attachment. The facility's policy and the lift manufacturer's instructions require staff to ensure all lifting accessories are correctly and securely applied before use. Despite staff training and annual competency checks, the staff did not follow these procedures, resulting in the resident's fall and injury. The clinical director confirmed that the facility's safe patient handling and mobility policy was not followed during this incident.