Failure to Ensure Safe Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident requiring a mechanical lift (Hoyer) for mobility. The resident, who had multiple diagnoses including type 2 diabetes, CHF, COPD, anxiety disorder, failure to thrive, morbid obesity, and CKD, was cognitively intact but fully dependent on staff for mobility and activities of daily living. The resident was at moderate risk for falls, completely incontinent, chair-bound, and unable to stand independently. During a transfer to bed using the Hoyer lift, two CNAs were assisting when the lift tilted sideways and fell, causing the resident to fall to the ground while still in the sling. The nurse arrived to find the resident sitting upright on the floor in the sling, and upon assessment, the resident reported pain in the buttocks. Further review revealed that one CNA could not recall whether the legs of the Hoyer lift were open or closed at the time of the incident, and the Administrator later stated the legs were only partially open. Facility policy required staff to ensure the lift was stable and locked before use. The resident was subsequently assessed, medicated for pain, and sent to the emergency room for evaluation after x-rays, where she was admitted to the hospital. The incident was documented and investigated by facility leadership.