Failure to Ensure Safe Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure a safe transfer for a resident who required total assistance with mobility and was ordered to be transferred using a Hoyer lift with the assistance of two staff members. The resident, who had diagnoses including diabetes, Parkinson's disease, and depression, was dependent on staff for all transfers and positioning. During a transfer from wheelchair to bed, the right front loop of the Hoyer lift pad was not properly secured to the lift, resulting in the resident falling forward from the lift. The incident led to the resident sustaining an abrasion to the right forehead and a right nondisplaced tibial plateau fracture, accompanied by pain and visible deformity of the leg. Documentation and staff interviews revealed that both staff members involved in the transfer, an LPN and a nurse aide, participated in attaching the Hoyer lift pad but failed to ensure all loops were properly secured. Neither staff member could confirm who attached which straps, and both had received prior education on mechanical lift use. The facility's investigation determined that the root cause of the incident was the failure to secure the right front Hoyer pad loop before lifting the resident. Observations and interviews with other staff confirmed the correct procedure for securing the lift pad, which was not followed during the incident. The facility's policies clearly prohibit neglect and require that all residents be protected from harm, including ensuring safe transfers. The failure to properly secure the Hoyer lift pad directly resulted in actual harm to the resident, as evidenced by the injuries sustained during the fall. The deficiency was confirmed by the DON and supported by witness statements, clinical documentation, and the facility's own investigation.