F0557

D

Failure to Honor Resident’s Choice and Dignity During Painful Hoyer Transfer

Hayward, California Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves a failure to honor a cognitively intact resident’s right to dignity, respect, and choice during a transfer and equipment change. The resident, who had chronic systolic CHF and morbid obesity, was admitted on an earlier date and had a BIMS score of 15, indicating intact cognition. During an episode in which his malfunctioning bariatric bed was being changed, he was lifted from bed in a Hoyer sling operated by a restorative nursing assistant, with rehab staff and outside Kaiser staff present. The process took longer than the resident anticipated, and while he remained suspended in the sling, he began experiencing increasing left hip pain. Staff adjusted the existing bariatric bed so it could be removed from the room, leaving the resident in the sling for an extended period.

Once the old bed was removed, instead of immediately returning the resident to bed as he requested due to escalating, “excruciating” left hip pain, Kaiser staff brought in a wheelchair/power chair and attempted to proceed with a wheelchair fitting. The resident repeatedly requested to be returned to bed and expressed that he did not want to continue with the fitting because of his pain. Staff attempted to support his left hip but continued with efforts to fit him to the chair while he remained in the sling and became increasingly agitated, screaming, cussing, and demanding to go back to bed. Only after the wheelchair/power chair was removed from the room was the new bariatric bed brought in and the resident returned to bed, at which point he verbalized displeasure with vulgar comments about the pain he experienced while in the sling. The facility’s own resident rights policy states that residents are to be treated with dignity and respect and allowed to make choices about daily life, which was not followed in this incident.