Improper Hoyer Lift Pad Use and Inadequate Supervision Resulting in Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and safe use of mechanical lift equipment during care for one resident, resulting in a significant injury. The resident had diagnoses including spinal stenosis, obesity due to excess calories, and muscle weakness, and required the use of a Hoyer lift for transfers. During care, the resident complained of left leg pain while care was being performed, cried out, and reported tightness in her legs and a loose stool overnight. She stated that no one hit her but that her legs had been held open to clean her, after which her left leg developed a bruise and became painful. Vital signs were within normal limits and respirations were easy at the time, but the resident’s daughter requested hospital transfer. Hospital documentation later identified a 9 x 7 x 16.6 cm hematoma within the soft tissue of the left medial thigh with a small spot of active bleeding. Facility documentation indicated that the resident required a Hoyer lift and that an incorrect Hoyer pad had been used during the incident. Based on policy review, clinical and facility record review, hospital records, and staff and resident interviews, surveyors determined that the facility did not ensure the area was free from accident hazards and did not provide adequate supervision and proper use of assistive devices for this resident, leading to the hematoma and transfer to the hospital.
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