F0684

D

Unsafe Hoyer Lift Transfer and Failure to Perform Required Safety Checks

Canal Winchester, Ohio Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe Hoyer lift transfer practices and adherence to established procedures for a resident who required total assistance with transfers. The resident had multiple diagnoses, including essential hypertension, type II diabetes mellitus, osteoarthritis, bilateral knee contractures, dementia, and a documented need for assistance with personal care. The resident’s MDS showed dependence for chair/bed-to-chair transfers, and the care plan called for transfers using a mechanical lift with three helpers. During an observed Hoyer lift transfer, one CNA operated the lift while the other CNA secured the resident in the sling. As the resident was raised and suspended in the air, one CNA removed the wheelchair from beneath the resident and moved it away.

The observation further showed that after moving the wheelchair, the second CNA went to the opposite side of the bed, leaving the resident suspended in the Hoyer lift without anyone guiding or stabilizing the resident in the sling toward the bed. In a subsequent interview, both CNAs and an LPN confirmed that staff did not provide support to the resident while the resident was suspended in the lift. When questioned about the process before initiating use of the Hoyer lift, the CNAs were unable to verbalize how to inspect the lift or assess the sling for safety prior to use and confirmed that this inspection process had not been completed. Review of the manufacturer’s manual and the facility’s Hoyer lift transfer policy showed that slings should be inspected before each use and that one person should stabilize the lift while a second person guides and stabilizes the resident and sling during transfer, which did not occur in this instance.