Failure to Safely Use Hoyer Lift Sling Resulting in Resident Fall and Injury
Penalty
Summary
A resident who was cognitively intact and had diagnoses including bilateral osteoarthritis of the knees and obesity, with care plans indicating the need for a mechanical lift for transfers and assistance with activities of daily living due to fall risk, was unsafely transferred from a wheelchair to a bed using a Hoyer lift. During this transfer, staff used a sling that the CNA later described as appearing too small for the resident’s body size, chosen because it was the sling available at the time. While the resident was being transferred, one of the sling’s loops/straps broke, causing the resident to fall directly to the floor and strike the base of the Hoyer lift. Following the fall, the resident was found sitting on the floor between the base of the Hoyer lift with visible bleeding from a laceration on the left shin and reported severe pain rated 10 out of 10, requiring pain medication. The LVN who responded confirmed that the sling was broken, and the resident was transferred to an acute care hospital, where staples were applied to close the laceration. The DON later stated that the fall could have been avoidable if staff had checked the slings, such as for loose threads, prior to use. The Hoyer lift manual’s maintenance safety inspection checklist specified that sling attachments should be checked each time they are used and that sling material should be inspected for wear, indicating that required pre-use inspection of the sling did not occur as specified.
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