Failure to Secure Hoyer Lift Pad Results in Resident Injury During Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure that a resident was free from a preventable accident during a transfer using a Hoyer lift. The resident, who had diagnoses including diabetes, Parkinson's disease, and depression, was assessed as totally dependent for transfers and required the use of a Hoyer lift with the assistance of two staff members. Physician orders and the care plan both specified this requirement. During a transfer from wheelchair to bed, the front right loop of the Hoyer lift pad was not properly secured, resulting in the resident falling forward from the lift, striking her face and leg. The incident was witnessed by two staff members, an LPN and a nurse aide, who both participated in attaching the Hoyer lift pad. Neither staff member could confirm who was responsible for securing the specific loop that failed. Documentation and interviews revealed that the right front Hoyer pad loop was not properly attached to the lift prior to the transfer. As a result, the resident sustained an abrasion to the right forehead and a right nondisplaced tibial plateau fracture, accompanied by pain and abnormal leg positioning. The facility's policy required a safe environment and proper use of mechanical lifts, and both staff members involved had received prior education on mechanical lift safety. Despite this, the failure to ensure all loops were securely fastened directly led to the resident's fall and subsequent injuries. Observations and interviews with other staff confirmed the correct procedure for securing the Hoyer lift pad, highlighting the deviation from protocol during the incident.