F0684

J

Failure to Assess Change in Condition and Perform Safe Hoyer Transfer Resulting in Severe Injuries

Liberty, Texas Survey Completed on 03-19-2026

Penalty

Fine: $24,845

Summary

The deficiency involves the facility’s failure to ensure a resident received timely assessment and care in accordance with professional standards of practice and the resident’s care plan after a reported change in condition. The resident was an elderly female with Alzheimer’s disease, dementia, prior cerebral infarction, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers, requiring a two-person Hoyer lift transfer at all times. Her care plan and Kardex both identified her as non–weight bearing and requiring Hoyer lift with two staff. On the afternoon of the day before the incident, documentation by an LVN indicated no edema or injuries, and a late-night note by another LVN documented edema but did not specify location, grade, or associated pain.

During the night shift, a CNA transferred the resident from wheelchair to bed using a Hoyer lift alone, despite knowing the resident required a two-person Hoyer transfer and acknowledging awareness that Hoyer lifts required two staff. The CNA reported not being trained on the Hoyer lift at the facility and not checking the Kardex due to lack of access to the electronic system. After the transfer, while providing incontinence care, the CNA noticed bruising on the resident’s left leg and skin tears on her arms near the wrists. The CNA stated she informed a CNA supervisor, who allegedly said the leg had always been like that and did not check it, and that she also informed the night-shift LVN that the resident appeared to be in pain and asked the LVN to look at the leg. The LVN reportedly responded that the resident would be screaming if she was in pain and later, when shown the resident’s left foot with edema around 5:10–5:15 a.m., told the CNA to elevate the leg and then continued providing care to other residents without immediately assessing the resident.

The LVN who had worked the prior day shift and returned for the morning shift stated that the resident had no bruises, edema, or skin tears when she left the previous evening. After receiving morning report, this LVN was asked by the night LVN to assess the resident at approximately 6:40 a.m. Upon pulling back the covers, she observed extensive new findings: discoloration and bruising to both arms and the right thigh, left lower extremity swelling and discoloration, multiple skin tears with missing top skin and no flaps, a knot on the right forearm, a scratch on the forehead, a large bruise on the back, fresh blood on the gown and blankets, and significant pain responses (grimacing, moaning, and frowning) when the resident was touched or moved. The resident was unable to articulate what had happened and denied falling or being harmed when questioned. Hospital evaluation documented a forehead abrasion, obvious deformity of the left lower extremity, severe hematoma of the right upper extremity, bilateral upper extremity contusions with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling, with concern for elder abuse noted. The facility’s investigation found no reported falls or incidents that could explain the injuries, confirmed that the night LVN had been notified of leg changes but did not promptly assess the resident, and classified the situation as an Immediate Jeopardy related to failure to assess and respond to a change in condition and to follow safe transfer requirements.