F0689

J

Improper One‑Person Hoyer Lift Transfer Resulting in Resident Head Injury

Bay City, Texas Survey Completed on 01-01-2026

Penalty

Fine: $16,280

Summary

The deficiency involves the facility’s failure to ensure the resident environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents, specifically related to mechanical lift transfers. An 83‑year‑old woman with dementia, heart failure, morbid obesity, and total dependence on staff for transfers and bed mobility was care planned to require a Hoyer lift with two staff for all transfers. She used a wheelchair and could self‑propel short distances but was otherwise dependent for mobility. The resident’s care plan and MDS documented that she required two‑person total assistance for all transfers, including bed to chair and toilet transfers.

On the night of the incident, a CNA who worked the 6 p.m. to 6 a.m. shift initiated a Hoyer lift transfer of this resident from bed to wheelchair alone, despite knowing the resident was a two‑person assist. The CNA reported that she chose to perform the transfer by herself because the other aide was busy and stated that “everybody does it by themselves” at the facility and she did not think anything bad would happen. During the transfer, the CNA described that the Hoyer lift arms attached to the sling were wobbling, the sling on the right side slipped off the hook, and the resident fell straight down, striking her head. The CNA observed blood on the floor and immediately notified the LVN on duty.

The LVN documented that the resident fell from the Hoyer lift during a transfer in her room, sustained bleeding to the back of the head, and complained of continuous pain to the back of her head, left shoulder, and left heel. On assessment, the resident’s blood pressure was elevated, she was oriented and obeyed commands, and her pupils were equal and reactive to light. The LVN and other staff found the resident lying on the floor with her head on top of one leg of the Hoyer lift and the other leg bent beneath her body, with a pool of blood around her head. EMS was called, and the resident was transported to a local hospital and then airlifted to a higher‑level facility’s Neuroscience ICU with diagnoses including brain bleeding, a subdural hematoma, and subarachnoid hemorrhages. The resident later reported that she fell during a Hoyer transfer, hit her head, and repeatedly stated that her head hurt.

Additional information gathered during the survey showed that the manufacturer’s instructions for the Hoyer lift, updated in November 2025, required at least two people to operate the lift during transfers. The facility’s in‑service records showed Hoyer lift trainings earlier in the year and again on the date of the incident, but the CNA who performed the transfer alone was not listed on those in‑services and could not recall when she last received Hoyer training, stating she might have had training at hire. Other CNAs interviewed stated that Hoyer transfers should always be done with two people, though one resident reported that staff usually performed Hoyer transfers with one person and identified a specific aide by first name as doing so. The Hoyer lift used in the incident had been inspected by the company earlier in the month and again after the fall, with no malfunctions identified; the equipment owner stated that if someone fell due to a wing becoming unbalanced, it would be because the person was not centered in the sling prior to the lift. An Immediate Jeopardy was identified related to these failures.