F0689

D

Single-Staff Operation of Hoyer Lift Contrary to Two-Person Transfer Requirements

Rosebud, Texas Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and use of assistive devices during a mechanical lift transfer for one resident. The resident was an adult female with epilepsy, morbid obesity, type 2 diabetes, chronic kidney disease, an unspecified bone disorder, heart failure, unspecified psychosis, major depressive disorder, and quadriplegia. Her MDS showed a BIMS score of 15, indicating little to no cognitive impairment, and documented that she used a manual wheelchair and was dependent on staff for bed mobility. Her care plan, last reviewed on 2/11/2026, required use of a Hoyer lift for transfers with an intervention specifying that all Hoyer transfers were to be performed by two staff members. The facility’s hydraulic lift policy stated that the number of staff to provide assistance should be determined by manufacturer recommendations.

On the survey date, an observation showed CNA A standing to the left of the resident’s bed and independently lowering the resident into bed using the Hoyer lift. A sign on the lift in the room stated that at least two staff members must assist during use of the lift. CNA B entered the room only after the resident had been lowered into bed and placed a box of gloves on the bed. CNA A acknowledged knowing that two staff members were required for Hoyer transfers and stated she was waiting for CNA B, who had gone to get larger gloves, and that they wanted to complete the transfer before lunch trays arrived. CNA B confirmed she had been trained that two staff were required for Hoyer transfers and stated she did not know why CNA A operated the lift alone. The DON and Administrator both stated that two trained staff members were supposed to operate the Hoyer lift and that CNA A had been trained and worked at the facility for many years.