Failure to Ensure Safe Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to ensure the safe use of a Hoyer lift during a transfer, resulting in a resident falling and sustaining multiple serious injuries. The staff did not properly secure the sling straps to the lift, leading to both lower straps detaching simultaneously and causing the resident to fall onto the metal leg of the lift and the floor. At the time of the incident, only one certified nurse assistant (CNA) and one nurse assistant (NA, still in training) were present, rather than the required two CNAs. The NA operated the lift while the CNA was not positioned to guide or support the resident during the transfer, contrary to facility policy and standard training, which require one staff member to operate the lift and the other to guide and stabilize the resident. The sling used during the transfer was found to have damaged, rigid, and stiff straps, which should not have been used according to the manufacturer's guidelines and facility procedures. Additionally, the sling lacked a label indicating its size, brand, or weight limit, and staff had not received training on how to select the correct size sling for residents. Instead, staff determined sling size by visual estimation. Both the CNA and NA confirmed that they had not been trained on proper sling selection prior to the incident, and the sling used was not verified to be the correct size for the resident. The resident involved had a history of spinal fusion and limited movement in both legs, requiring total assistance from two staff members for transfers. As a result of the fall, the resident sustained four fractures in the lower back and pelvis, experienced severe pain requiring increased narcotic pain medication, required supplemental oxygen, and was hospitalized. Prior to the fall, the resident was independent in certain activities and did not require oxygen. The incident led to significant physical and emotional distress for the resident, including the inability to attend medical and personal appointments.