Failure to Report Hoyer Lift Fall With Injury as Unusual Occurrence
Penalty
Summary
Facility staff failed to report an unusual occurrence to the State Agency after a resident fell during a Hoyer lift transfer and sustained an injury requiring hospital treatment. The resident, who had a BIMS score of 15/15 indicating normal cognition, reported that a few months prior he fell out of the Hoyer lift while being transferred from wheelchair to bed when a strap of the sling broke, causing him to land on the floor and suffer a deep cut on his leg that required staples in the emergency room. Progress notes from the date of the incident documented that the resident stated he had been dropped, complained of 10/10 pain, was given Norco, and was sent to an acute hospital for further evaluation. The LVN who assessed the resident confirmed that the sling was broken. The DON acknowledged awareness of the fall related to the broken loop of the Hoyer lift sling but stated the incident was not reported to the California Department of Public Health because it did not occur to her that it was an unusual occurrence requiring reporting, as the cause of the fall was known. The Administrator similarly stated that it is unusual for a resident to fall or have injuries related to Hoyer lift use and that such unusual occurrences are reportable, but he did not report this fall because the facility was focused on the cause of the fall and managing the resident’s injuries. This inaction was inconsistent with the facility’s Unusual Occurrence Reporting policy, which requires reporting incidents affecting residents’ health, safety, and welfare to appropriate agencies by telephone within 24 hours and submission of a written report within 48 hours.
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