Failure to Follow Mechanical Lift Transfer Requirements for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a required fall-prevention intervention for a resident identified as a fall risk and dependent on staff for all ADLs and transfers. The resident had vascular dementia, glaucoma, a history of bilateral knee replacements, was non-ambulatory, and had been deemed incapable of making medical decisions by two physicians. The medical record contained a physician’s order dated 03/08/2024 requiring use of a Hoyer (mechanical) lift for all transfers, and the fall prevention/ADL care plan included an intervention dated 07/31/24 directing staff to use a Hoyer lift for all transfers. Despite these orders and care plan interventions, the resident was later found to have a fractured right distal femur, classified as an injury of unknown source. The facility’s investigation into the injury revealed that on 07/07/25 during the 3–11 pm shift, a GNA transferred the resident without following the ordered intervention. An employee warning notice documented that the GNA initially stated they had used a Hoyer lift with a second staff member for the transfer, but later admitted to performing the transfer alone. The DON reported that review of surveillance footage from the hallway outside the resident’s room showed the GNA entering the room alone with a Hoyer lift and later exiting alone with the lift, with no second staff member observed entering to assist. The facility became aware of the resident’s right distal femur fracture on 07/11/25 at 9:27 pm, and the resident was unable to provide any information about when or how the fracture occurred.
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