F0689

G

Improper Hoyer Lift Use Leads to Resident Fall and Pelvic Fracture

Parma, Ohio Survey Completed on 09-18-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe use of a mechanical (Hoyer) lift during a resident transfer, resulting in a fall and injury. The resident involved had diagnoses including bipolar disorder, post-traumatic stress disorder, and hemiplegia with hemiparesis following a cerebrovascular event affecting the left non-dominant side, and was dependent on staff for all ADLs. Physician orders required use of a mechanical lift for all transfers, and repeated fall risk assessments consistently identified the resident as being at high risk for falls.

On the day of the incident, at approximately 10:30 A.M., a charge nurse heard a loud noise and entered the resident’s room, finding the resident lying on the floor next to the bed with two CNAs present and a wheelchair and Hoyer lift nearby. Immediate assessment revealed no visible injuries, but the resident reported slipping from the Hoyer lift sling and complained of pain to the left elbow and left side of the face. The resident was kept on the floor for safety until further evaluation, and EMS, the facility NP, and the resident’s family were notified.

Subsequent hospital evaluation documented that the resident reported pain to the left side of the head, left elbow, and left hip, and pelvis radiographs showed acute fractures of the left superior and inferior pubic rami. The facility’s investigation determined that during the transfer from bed to wheelchair, one of the Hoyer lift pad straps had not been secured to the spreader bar, causing the resident to slip from the sling and fall. Written statements from both CNAs confirmed the failure to secure the strap, and the DON confirmed that the injury was caused by improper securing of the Hoyer lift sling. The resident later expressed apprehension about being transferred with the Hoyer lift following the incident.