F0689

D

Improper Use of Mechanical Lift Emergency Release During Resident Transfer

Marion, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure safe use of a mechanical lift during a transfer for a resident who was quadriplegic, dependent for transfers, and required a Hoyer lift per the care plan. The resident had intact cognition with a BIMS score of 15 and diagnoses including quadriplegia, Type II diabetes mellitus, chronic respiratory failure, and Guillain-Barré syndrome. During an evening transfer from wheelchair to bed using a Hoyer lift, a CNA activated the emergency release mechanism, causing the resident to be rapidly lowered approximately 8–12 inches onto the bed instead of using the standard down button. The Hoyer lift manual specifies that safe lowering is to be performed by pressing the down button and notes that injury or damage may occur if instructions are not followed.

Following the incident, the resident complained of right shoulder pain. An LPN assessed the resident, and subsequent imaging showed degenerative changes in the right shoulder joints without acute fracture or dislocation. The resident’s medical record documented multiple episodes of reported shoulder pain in the days after the incident, with pain scores ranging from four to nine and administration of as-needed oxycodone and nonpharmacological interventions, which were recorded as effective. During interviews, the resident reported that a former shoulder injury had been aggravated when the aide activated the emergency release, causing the rapid drop onto the bed. Staff interviews and written statements confirmed that the CNA intentionally pulled the emergency release during the transfer because she wanted to complete the transfer quickly, rather than using the proper lowering method described in the lift manual.