F0689

G

Improper Hoyer Lift Operation and Inadequate Supervision Resulting in Resident Fall and Injury

Ozark, Missouri Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and assistance with mechanical lifts, resulting in a resident falling from a Hoyer lift and sustaining injuries. The facility’s own fall protocol required immediate physical and neurological assessment, investigation of the incident, physician and responsible party notification, and completion of a fall incident report after any unintentional change in position to the floor. Resident #2, cognitively intact and dependent on staff for toileting, dressing, and mobility, had a care plan requiring use of a Hoyer lift with assistance from two staff for transfers. Despite this, the resident reported that during a transfer from wheelchair to bed using a manual Hoyer lift, the lift became difficult to move across the floor, staff gave it a strong push, and the lift tipped over, landing on the resident.

Record review of the facility’s event report documented that two staff applied the Hoyer straps, raised the resident, and moved the lift toward the bed. As the resident’s body neared the edge of the bed, the lift tipped to the left, causing the resident to fall from the highest position, striking the chin and back of the head and sustaining a laceration that required sutures to the chin. The resident later exhibited bruising around both eyes and a healed scar from the bottom lip to the underside of the chin, and reported ongoing decreased sensation and numbness in the lower half of the face, affecting eating and talking. The administrator, who was called to the room immediately after the incident, did not observe any evidence that the lift was broken or malfunctioning and concluded that the lift simply tipped over during use.

Interviews with staff revealed inconsistent and unsafe practices in operating Hoyer lifts and a lack of specific training. One CNA present during the incident stated that no one was operating the lift when it tipped; instead, both CNAs were on either side of the resident pulling on the sling to move the lift, at which point it flipped over. Another CNA present stated that on the day of the incident, one CNA was operating and moving the lift toward the bed while the other CNA was on the opposite side of the bed and not guiding the resident or lift. Multiple staff, including CNAs, CMTs, an LPN, the ADON, and the administrator, described the expected standard that Hoyer lift legs must be open, two staff must be present, one staff should operate the lift while the other guides and positions the resident, and the legs should be locked when raising or lowering the resident. However, one CNA reported not receiving specific Hoyer training, and another CNA and other staff expressed concerns that the facility’s manual Hoyer lifts seemed unstable or old, though the maintenance director stated he had not been informed of any broken lifts and had not yet completed the monthly safety check. Observation of a later transfer using a hospice-owned Hoyer showed staff questioning strap color and whether to attach the middle strap, the sling positioned above the resident’s head causing leaning and a crooked neck, and the operator lowering the resident without locking the wheels, further demonstrating improper and inconsistent use of mechanical lifts.

Additional interviews showed that staff had differing understandings of whether pulling on the sling could cause a lift to tip, with some acknowledging that pulling on the sling could create a balance concern and cause an accident, while another CNA did not believe that pulling on the sling without someone operating the lift could cause tipping. The medical director reported he did not recall being notified of the incident at the time, though his notes reflected that the facility had reported the lift as broken, and he confirmed awareness of the resident’s ongoing lack of sensation in the lower portion of the face. The maintenance director stated that maintenance was responsible for inspections and repairs of facility-owned Hoyer lifts and that lifts with reported issues would be tagged out of service, but he had not yet performed the monthly safety check and had not received any staff reports of broken lifts. Overall, the observations, interviews, and record review showed that staff were not consistently trained or following safe operating procedures for mechanical lifts, and that the facility failed to ensure safe operation of the Hoyer lift and adequate supervision during transfers, resulting in the resident’s fall and injury.