Improper Hoyer Lift Technique Leads to Resident Fall and Fractured Humerus
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide safe mechanical lift transfers for a resident who required staff assistance and a Hoyer lift for all transfers. The resident had morbid obesity, COPD, osteoporosis, bilateral impairment, and moderate to severe cognitive impairment, and was dependent on staff for transfers, toileting, and bathing per MDS and CAA assessments. These assessments documented that the resident required a mechanical lift for transfers and was dependent on staff for mobility-related ADLs. On the date of the incident, two CNAs were transferring the resident using a Hoyer lift from a wheelchair to a recliner. According to the facility’s incident report and notarized witness statements from both CNAs, one CNA operated the Hoyer lift from the front while the other CNA guided and positioned the resident from behind the recliner. As the resident was being lowered into the recliner, the top left sling strap/loop came off the Hoyer hook, causing the resident to slide out of the sling and fall to the floor. The resident immediately complained of left shoulder pain and right shin pain, and staff observed a bruise on the right wrist. The resident was sent to the ER, where imaging confirmed a left humerus fracture measuring 3.1 cm, and the resident returned with a shoulder abduction immobilizer. An administrative nurse later inspected the lift and sling and found both to be functioning within normal limits. During subsequent transfer training with the involved CNAs, the administrative nurse observed that when the CNAs placed the sling strap loops onto the lift, they did not ensure there was tension on the straps before raising the lift, which allowed the lift sheet to shift to one side and the loops to come off the lift. This improper technique directly contributed to the sling strap detaching from the lift and the resident’s fall and injury.
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