F0689

D

Improper One‑Person Hoyer Lift Transfer Leads to Resident Fall

Phoenix, Arizona Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate assistance and proper use of assistive devices, specifically a mechanical (Hoyer) lift, for a resident identified as being at risk for falls. The resident had multiple diagnoses, including bipolar disorder, COPD, anxiety disorder, extrapyramidal and movement disorder, hyponatremia, and age-related osteoporosis, and was care planned as at risk for falls related to high‑risk medication use, incontinence, poor mobility, hand contractures, and involuntary movements. The care plan interventions included anticipating and meeting needs, ensuring a reachable call light, prompt response to requests for assistance, maintaining a safe environment, and using a Hoyer lift for transfers with monitoring for safety. The resident also had an ADL self‑care performance deficit care plan that specified the need for staff assistance with ADLs due to pain and contractures and identified Hoyer lift transfers as part of the resident’s care.

On a morning in November, the resident reported to a CNA that he had fallen at approximately 5:30 a.m. The nurse’s post‑fall assessment documented that the resident stated he had been helped with a Hoyer lift by a CNA who forgot to remove the sling, and that he slid down to the floor. The RN assessment noted the resident’s range of motion was within normal limits for his baseline, with contractures to his legs and hands, intact skin without bruising or abrasions, and resident‑reported mild to moderate pain in the knees and left hip. Neuro checks were within normal limits, and the resident denied hitting his head. An X‑ray of the left hip and knee later showed no acute fracture or dislocation, with intact osseous structures and modest joint space narrowing. A fall risk evaluation completed in November documented that the resident was chair‑bound, had 1–2 falls in the last three months, was at risk for falls with a score of 14, and had a BIMS score of 11 indicating moderate cognitive impairment.

Interviews and facility documentation described the circumstances leading to the fall and the manner in which the Hoyer lift was used. The resident’s representative stated that the resident told her a staff member attempted to get him up with a mechanical lift in the dark, that the resident asked for the light to be turned on, and that the staff member proceeded anyway, resulting in a fall. The resident stated that the CNA came alone at about 5:30 a.m. to assist him with the Hoyer lift, hooked the sling strap to the lift, and that the strap felt stuck; despite the resident telling the CNA it was stuck, the CNA continued pulling until the resident suddenly fell onto his bottom. The resident reported that he already had trouble with his left knee and that his leg became worse after this incident. Review of the CNA’s employee file showed a disciplinary action documenting that the CNA transferred the resident from bed to wheelchair alone using the Hoyer lift, did not have a second staff member present, and that the resident slipped from the wheelchair onto the floor. The documentation also stated that the CNA failed to report the incident to a nurse and got the resident up before an assessment for injuries could be completed.

Multiple staff interviews confirmed the facility’s established process for Hoyer lift use and contrasted it with what occurred for this resident. CNAs and licensed nursing staff consistently stated that the facility’s process requires two staff members for Hoyer transfers, that all four sling loops must be correctly attached and double‑checked before lifting, and that the sling must be unhooked after the transfer is completed. Staff described that one staff member operates the lift while the other supports and guides the resident’s body, and that improper hookup or incomplete securing of the sling can allow a resident to slip off. The DON stated that the facility’s process is to have two staff members perform a Hoyer transfer, with the sling placed under the resident, color‑coded loops attached to the lift, the resident lifted and transferred to the receiving surface, and the sling then removed. The DON acknowledged that, for this resident, the staff member did not use a second person and forgot to unhook the sling, which resulted in the resident sliding from the chair to the floor. A written policy titled “Lifting Machine, Using A Mechanical,” revised in October 2017, specified that at least two nursing assistants are needed to safely move a resident with a mechanical lift, underscoring that the actions taken with this resident did not follow the facility’s own policy and procedures for safe mechanical lift use.