Failure to Follow Hoyer Lift Transfer Requirements for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred in accordance with physician orders and the resident’s care plan, which required use of a Hoyer mechanical lift with a medium purple sling and assistance of two staff for all transfers. The resident had multiple diagnoses, including COPD, lumbago with sciatica on both sides, and chronic atrial fibrillation, and had a care plan intervention in place specifying mechanical lift transfers. A physician order also directed that a Hoyer lift be used for all transfers on all shifts. The resident’s MDS reflected moderate cognitive impairment. The incident came to light when the resident’s daughter reported that the resident complained of back pain after being gotten out of bed the previous evening and expressed concern that the pain was related to how staff had transferred the resident. The daughter contacted the local police department, and an officer subsequently interviewed the resident. The resident reported that an aide, described as a black female in her late 20s, picked her up under both armpits and placed her in a wheelchair, and that she experienced pain during the move from bed to chair. This description did not include the use of a Hoyer mechanical lift as required by the care plan and physician order. During the facility’s investigation, one CNA stated in a witness statement that she had cared for the resident on the relevant day shift and had transferred the resident twice, from bed to chair and later from chair back to bed, with assistance from another CNA. She acknowledged having a gait belt but not using it and stated she did not know the resident required a Hoyer lift, and that the resident appeared comfortable and voiced no concerns at the time. The assisting CNA, in a later telephone interview, claimed that a Hoyer lift had been used and alleged the family was lying. The Administrator, however, confirmed that the facility determined the two CNAs had not used a Hoyer mechanical lift and had instead body-lifted the resident from bed to chair and back, contrary to the resident’s care plan and physician orders.
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