F0689

J

Single-Staff Hoyer Transfer and Delayed Assessment Lead to Severe Resident Injuries

Liberty, Texas Survey Completed on 03-19-2026

Penalty

Fine: $24,845

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.