Failure to Ensure Safe Hoyer Lift Transfer Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident using a Hoyer lift, resulting in the resident falling and sustaining a right femur fracture that required surgery and an extended hospital stay. The incident took place during a transfer from bed to wheelchair, when the Hoyer sling snapped, causing the resident to fall to the floor. The resident, who had diagnoses including a previous right femur fracture, morbid obesity, type II diabetes, and schizoaffective disorder, was alert and oriented at the time and reported ongoing pain following the incident. Staff interviews revealed that the CNA responsible for the transfer, along with an orientee, retrieved a Hoyer sling from the laundry area without thoroughly inspecting it before use. The CNA admitted to not noticing the sling's frayed edges prior to the transfer and only realized the sling was old and slightly ripped after the resident had fallen. The sling was not in good condition and should not have been used for the transfer. Laundry staff, who were contracted employees, reported that prior to the incident, slings were washed and stored in the laundry room without a specific protocol for inspecting their condition. The Director of Nursing and the Administrator confirmed that the sling used during the incident was not in acceptable condition for use. The failure to properly inspect and ensure the integrity of the Hoyer sling directly led to the resident's fall and injury.