Failure to Provide Required Two-Person Assistance During Hoyer Lift Transfer Resulting in Injury
Penalty
Summary
A resident with osteoporosis, dementia, and adult failure to thrive, admitted in 2019, was care planned and documented on the Kardex as requiring full mechanical (Hoyer) lift transfers with two-person assistance for all transfers. Facility policy on mechanical lifts, dated 02/26/09, required at least two nursing assistants to safely move a resident with a mechanical lift. Certified Nurse Aide (CNA) #1 had completed the facility’s required competency for mechanical lift transfers and acknowledged knowing both the policy and that this resident required two staff for all transfers. On 12/30/25 at approximately 6:00 P.M., CNA #1 attempted to transfer the resident alone using a Hoyer lift, without another staff member present, contrary to the resident’s care plan, Kardex instructions, and facility policy. During the transfer, the resident’s shoulders remained suspended three to four inches above the mattress when CNA #1 disconnected the right upper sling strap, causing the resident’s upper body to drop quickly onto the bed and the sling bar to swing into the right side of the resident’s head. The resident immediately began bleeding from the right temple area. Subsequent nursing assessment noted a deep open head wound with significant bleeding, and the resident was sent to the hospital ED, where he/she was diagnosed with a right lateral temple hematoma and ulceration, minimally displaced proximal and distal left clavicular fractures, and acute fractures of the left superior and inferior pubic ramus. Multiple staff, including CNAs and the DON, confirmed it was well-known facility policy that all Hoyer lift transfers required two staff members.
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