Failure to Ensure Safe Use of Mechanical Lifts During Resident Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not providing adequate supervision and safe equipment use during resident transfers. Specifically, a resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers was involved in an incident where a manual Hoyer lift tipped over during a transfer from wheelchair to bed. The staff did not fully extend the lift's legs, causing the lift to become unstable and tip, resulting in the resident falling to the floor. Although the resident did not sustain injuries, the incident was attributed to improper use of the lift equipment. Observations revealed that the facility's electric Hoyer lifts were stored in a back hallway among other appliances and were not easily accessible. Staff interviews indicated that the electric lifts had been non-operational for an extended period due to battery issues, leaving only a manual Hoyer lift available for use. Multiple staff members reported that the manual lift felt flimsy and had a tendency to tip, even when used according to instructions. Some staff stated they had reported these concerns to management, but were told the issues were due to user error. Additionally, not all staff received training or competency assessments on the use of the manual Hoyer lift, and some staff reported never receiving education on its use. Documentation showed that the resident required a Hoyer lift for all transfers, and the care plan reflected this need. The facility's investigation identified improper use of the lift as the root cause of the incident. However, the investigation and subsequent staff training were incomplete, as not all nursing staff were included in the competency assessments or in-service education. Furthermore, communication regarding the operational status of the electric Hoyer lifts was inconsistent, with some staff unaware that the electric lifts were available for use again.