Single-Staff Hoyer Transfer and Delayed Assessment Lead to Severe Resident Injuries
Summary
The deficiency involves the facility’s failure to ensure safe transfers and adequate supervision during a mechanical lift transfer for one resident, resulting in serious injuries. The resident was an elderly female with Alzheimer’s disease, dementia, prior stroke, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers. Her care plan and Kardex specified that she was non–weight bearing and required a Hoyer lift with two staff for all transfers. Earlier on the day in question, she had been seen by facility physicians and nursing staff, and had received a shower and Hoyer transfer with two staff, with no bruises, skin tears, edema, or leg injury documented or observed. On the evening and night shift, a CNA assigned to the resident’s hall was instructed to put the resident to bed. The CNA reported that she took a Hoyer lift she had used on another resident and transferred this resident from wheelchair to bed by herself, despite knowing that Hoyer transfers required two staff and that the resident was a two-person Hoyer transfer. She stated she did not ask for help and acknowledged she had been trained that Hoyer lifts required two staff, although she also claimed she had not been trained on the Hoyer at this facility and said she did not check the Kardex because she did not have access. Another CNA confirmed that all Hoyer transfers were supposed to be done with two staff and that the resident’s requirements were available in the Kardex. The facility’s written Safe Resident Handling/Transfers policy required two staff for mechanical lift transfers and mandated that transfers be performed according to the resident’s plan of care. After the single-staff Hoyer transfer, the CNA and another aide assisted with repositioning the resident in bed. During this time, skin tears and bruising on the resident’s arms were observed. The assisting CNA reported that the skin tears appeared bloody and asked what had happened; she was told by the primary CNA that the injuries were old and that the nurse was aware. The primary CNA stated she informed the nurse that the resident appeared in pain, but the nurse allegedly responded that the resident would be screaming if she were in pain. The CNA also reported noticing bruising on the resident’s left leg and said she told her supervisor and the nurse, and was told the leg was always like that or that it was edema and to elevate it. The nurse on duty acknowledged being notified around early morning that the resident’s leg appeared bruised or swollen but did not immediately assess the resident, instead instructing that the leg be elevated while she continued care for another resident. By the following morning, when the day-shift LVN assessed the resident at the request of the night nurse, extensive injuries were found. The assessment revealed bilateral bruising to both arms, multiple skin tears with missing top layers of skin and no flaps, a large bruise on the back, a scratch on the forehead, and swelling, discoloration, and obvious deformity of the left lower extremity. The resident grimaced and moaned with touch or movement. Hospital evaluation documented a forehead abrasion, severe hematoma and contusions of the upper extremities with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling. Police photographs showed purple and red bruising on both hands with fresh and dried blood on the sheets, and the left leg bruised, purple, inflamed, and turned in an abnormal direction. There were no documented falls or incidents that could explain these injuries, and staff interviews did not identify any reported event, leaving the single-staff Hoyer transfer and subsequent lack of timely assessment after reported changes in condition as the central actions and inactions leading to the deficiency. The facility’s internal investigation confirmed that there were no abnormal findings on the resident earlier that day, including during a shower and physician visits, and that no staff reported any fall or incident during the night. The CNA who performed the transfer admitted using the Hoyer lift alone for this dependent, non–weight-bearing resident, contrary to the care plan, Kardex, and facility policy. The night nurse acknowledged failing to assess the resident after being notified of a change in her leg’s condition. The day nurse, who had last seen the resident without injuries the prior evening, found extensive new bruising, skin tears, and leg deformity the next morning. The combination of a one-person mechanical lift transfer for a resident care-planned for two-person Hoyer use, failure to follow the safe transfer policy and plan of care, and failure to promptly assess and document a reported change in condition led to the identified deficiency in ensuring the environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents.
Removal Plan
- Completed facility-wide skin assessments with no new or abnormal findings identified.
- Conducted environmental and safety rounds with no hazards or abnormal findings identified.
- Conducted resident safe surveys; residents reported they felt safe in the facility environment.
- Provided staff education on abuse, neglect, and exploitation policies.
- Completed mechanical lift competencies with nursing staff.
- Reviewed electronic records of residents; no issues identified with assessments.
- Held an AD HOC QAPI meeting with the interdisciplinary team and involved police notification, social work, and the Regional Nurse; implemented ongoing daily monitoring of residents.
- Implemented staff training and competency testing/demonstration covering abuse, neglect, reporting, documentation, transfers, resident assessment, and pain assessment.
- Conducted in-services for all direct care staff (in person and/or via phone); staff not present were not permitted to work their assignment until in-serviced; new hires to be in-serviced during orientation; agency staff to be in-serviced prior to working their floor assignment.
- Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, abuse coordinator identification, and immediate reporting of abuse/neglect with 100% staff trained.
- Completed nursing staff training and competencies for skin assessment and pain assessments with 100% nursing staff trained.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure effective fall alarms and supervision: two residents had Smart Caregiver monitoring devices set to LOW volume, and one resident's bed alarm did not alert staff before the resident was found on the floor after an unwitnessed fall. One resident had dementia, osteoporosis, prior TIA, and cognitive impairment and was fully dependent on staff, while staff also found that a second resident's bed and recliner alarms did not activate properly during testing.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper Mechanical Lift Transfers: A resident with dementia, spinal cord dysfunction, and dependence for transfers was supposed to be moved with a full-body mechanical lift and two staff members, but a TMA stated she transferred the resident alone. The resident reported that staff sometimes used only one person for lift transfers because of staffing shortages, while other staff and the DON stated this was unsafe and against policy.
Two residents were involved in accident-hazard deficiencies. One resident with cancer, PVD, and Alzheimer’s disease was observed in a wheelchair with feet extending past short footrests, with the lower legs resting against the hard footrests despite a care plan entry for padding. Another resident with dementia and a hx of falls had an unwitnessed fall, but ordered orthostatic BP monitoring was not completed accurately and staff reported no post-fall PT referral was received.
A resident was given a new electric wheelchair without a prior therapy assessment and could not stop the chair, causing it to strike a bed frame and resulting in a leg laceration, tibia/fibula fractures, and a syncopal episode from blood loss. Another resident with cognitive impairment and high fall risk continued to self-transfer and fall, but the care plan was not updated with new fall interventions after repeated incidents.
A CNA used a Hoyer lift alone to weigh one resident, and another CNA was observed using a Hoyer lift alone to weigh a second resident. One resident’s care plan called for a 2-assist Hoyer lift, and the facility’s lift competency checklist and policy both required two caregivers for mechanical lift use; the DON and Director of Therapy also stated that two staff members are always required.
Failure to Ensure Effective Fall Alarms and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective use of assistive fall-prevention devices for two residents who were reviewed for fall precautions. One resident had diagnoses including unspecified dementia, age-related osteoporosis, a history of transient ischemic attack, and cognitive impairment, and was described by the POA as weak, bedbound, and unable to participate in physical therapy after a prior right femur fracture. The resident was completely dependent on staff for eating, hygiene, mobility, and toileting, and the care plan included a bed alarm per orders. The resident was found on the floor next to the bed after an unwitnessed fall. The POA reported receiving a call from the facility that the resident had been found on the floor and was not injured, and stated the resident frequently forgot to ask for help and had tried to get up without assistance before. A nurse stated the bed alarm was not heard when the resident fell, and the facility was unable to provide evidence that the bed alarm functioned as intended or alerted staff before the resident was found on the floor. The event report identified the fall as unwitnessed and did not indicate that a bed alarm alerted staff. The facility also failed to ensure the Smart Caregiver sensor pad monitoring system used for another resident was functioning properly and set at an audible volume. Two Smart Caregiver monitor boxes at the nurses' station for that resident's bed and recliner were observed set to LOW volume, and the chime settings faced the back wall of the desk. When a CNA tested the recliner alarm from the resident's room, the monitor at the nurses' station did not illuminate or sound an alert on either attempt. The CNA changed the batteries but did not retest the device, and both CNAs stated they could hear alarms only if they were near the nurses' station and did not recall training on operation or testing of the devices. The facility director stated the facility did not perform preventive maintenance on the devices and relied on staff to ensure they functioned properly.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure transfers were performed according to R24’s assessed needs, care plan interventions, and facility policy. R24’s records showed she had diagnoses including non-traumatic spinal cord dysfunction, diabetes, dementia, depression, heart failure, and asthma. She was dependent on staff for toileting and transfers, was frequently incontinent of bowel and bladder, and had care plan directions for assistance with transfers using a full-body mechanical lift and two staff members. During interviews, a TMA stated she transferred R24 with the full-body mechanical lift by herself because R24 needed to use the bathroom and she felt the transfer was safe. R24 stated staff sometimes transferred her with only one staff member and said they told her there was not enough staff. Other staff interviewed stated transfers with the full-body mechanical lift using one staff member were unsafe and should not occur. The facility policy for using a mechanical lift stated that at least two trained associates are needed to safely move a resident with a mechanical full-body floor-based lift or ceiling/overhead full-body lift.
Unsafe Wheelchair Fit and Incomplete Post-Fall Monitoring
Penalty
Summary
The facility failed to provide an environment free from accident hazards for two residents. Resident 27 was readmitted with diagnoses including cancer, peripheral vascular disease, and Alzheimer's disease and was sometimes able to make needs known. On multiple observations, Resident 27 was seated in a slightly tilted back wheelchair with feet extending beyond the footrests, and the back of the lower legs rested against the hard footrests above the ankle/heel area. A pillow was observed either on the floor or behind the legs rather than padding the footrests. The focused care plan for skin integrity included padding to wheelchair footrests, and staff interviews confirmed the footrests were too short and needed adjustment or replacement, but staff had not notified therapy or otherwise addressed the wheelchair fit. Resident 50 was admitted with diagnoses including dementia, history of falls, and UTI and was sometimes able to make needs known. The care plan identified the resident as at risk for falls. After an unwitnessed fall in the 300 hallway, the incident investigation added interventions to monitor orthostatic blood pressures and refer to physical therapy. However, the record showed an orthostatic blood pressure order on 05/20/2026 was not completed, and subsequent orthostatic blood pressures recorded the same blood pressure and pulse for all three positions on 05/22/2026, 05/23/2026, and 05/24/2026. Staff later stated they had not received a post-fall therapy referral, and the DNS stated the resident should have had orthostatic blood pressures taken accurately to rule out orthostatic hypotension.
Failure to assess electric wheelchair use and update fall interventions
Penalty
Summary
The facility failed to comprehensively assess a resident for the use of an electric wheelchair and failed to develop new interventions to reduce fall risk for another resident. The report states that the facility’s policies required a device evaluation before an electric wheelchair was initiated, resident education and consent, and an updated service plan identifying device use and other interventions. The fall management policy required individualized care plan updates, a systematic review after each fall, identification of root cause, and review of prior interventions when new interventions were implemented. Resident 73 was admitted with weakness and lymphedema and had an above-the-knee left leg amputation, requiring assistance with bed mobility, transfers, and locomotion. The resident’s record showed cognitive intactness, lower extremity impairment, supervision or touch assistance for bed-to-chair transfers, and use of a manual wheelchair. On 4/17/26, a newly issued electric wheelchair was delivered and the resident was assisted into it. The resident reported that the representative showed how the chair worked but not enough, and that the resident did not know how to stop it. The resident then returned to the room, could not stop the chair, and the chair continued forward into the bed, causing the resident’s right leg to strike the metal bed frame. The resident sustained a five-centimeter laceration to the right anterior lower leg, fractures of the right tibia and fibula, and a brief syncopal episode secondary to blood loss. The resident also received an anticoagulant, which contributed to significant bleeding. The clinical record contained no evidence that the resident had been assessed to safely operate the electric wheelchair before use. Resident 3 was admitted with a right total hip replacement with deep hardware removal and post-traumatic osteoarthritis of the right hip. The resident had a high fall risk on Morse Fall Scale assessments, cognitive impairment on OT evaluation, and a PT evaluation showing a score of zero on the Short Physical Performance Battery, indicating high fall risk and increased risk of mobility disability. The resident fell on 3/31/26 after getting up independently and sustained a right femur fracture requiring surgical repair, and fell again on 5/12/26 after getting up independently and sustained a skin tear to the right elbow. The care plan identified fall risk and included reminders to use the call light, non-skid socks, and one-person assistance for toileting and transfers, but revisions to the care plan did not add new or amended fall prevention interventions. Staff statements indicated the resident continued to self-transfer and toilet without assistance, staff believed the resident was independent, and the existing fall prevention interventions were ineffective.
Unsafe One-Person Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure safe use of a mechanical lift for 2 of 3 residents reviewed for accidents. During an observation on 6/2/2026 at 8:42 AM, Resident #4 was lying on his bed on top of a Hoyer pad while CNA Staff K stood on the right side of the bed with a mechanical lift; the lift hand bags were observed over the resident, and no other staff member was in the room. Staff K stated that he was weighing Resident #4 and that normally only one person uses the Hoyer lift for weights, although the resident’s care plan documented a Hoyer lift with 2 assist. On 6/4/2026 at 10:15 AM, CNA Staff D was observed using a Hoyer lift alone to obtain Resident #13’s weight, with the resident lifted approximately 12 inches off the mattress in the sling and no other staff present. Staff D stated that he was performing weekly weights and most of the time did the weights using the Hoyer lift by himself. Resident #13’s MDS Section GG coded the resident as dependent, and the facility’s mechanical lift competency checklist stated that two caregivers are present, while the facility policy for using a mechanical lifting device stated that at least two nursing assistants are needed to safely move a resident with a mechanical lift. The DON and Director of Therapy both stated that a mechanical lift should always be used by two staff members.
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