Failure to Maintain Safe Transfer Equipment Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a mechanical Hoyer lift, resulting in actual harm. The incident occurred when a staff member attempted to transfer a resident with significant medical needs, including cerebral palsy, diabetes with polyneuropathy, morbid obesity, and heart failure. During the transfer, the Hoyer pad strap broke, causing the resident to fall and sustain bilateral femur fractures and an L1 compression fracture, which required hospitalization and surgical intervention. Multiple staff interviews confirmed that the Hoyer pads were in poor condition prior to the incident, with several staff members having reported their concerns to administration over a period of months. Despite these repeated reports, no action was taken by management to replace the defective equipment until after the resident's fall. Staff also confirmed that the facility did not have a routine inspection plan in place for the Hoyer pads before the incident occurred. Facility policy required that two nursing assistants be present for mechanical lift transfers and that all equipment be in good condition. On the day of the incident, only one staff member was actively assisting with the transfer, while the second was present in the room but not directly involved at the time of the fall. The lack of timely equipment maintenance and failure to follow established safety protocols directly contributed to the resident's injury.