Description of Event or Problem · 1
THIS RESIDENT WAS BEING TRANSFERRED FROM HER BED INTO HER RECLINER VIA THE HOYER MECHANICAL LIFT BY TWO STAFF: CNA AND NA. THEY REPORTED THAT THEY HEARD A SNAP AND THE FRONT RIGHT SLING STRAP CAME OFF THE HOYER SLING HOOK, DUMPING THE RESIDENT FORWARD, FALLING ONTO THE FLOOR. MULTIPLE NURSES RESPONDED IMMEDIATELY. RESIDENT WAS IN PRONE POSITION, FACING THE FLOOR SLIGHTLY ON HER RIGHT SIDE; ARMS FLEXED, THE RIGHT ONE BENEATH HER. LEGS WERE STRAIGHT. SHE REMAINED ALERT AND ORIENTED X 4. SHE WAS VERBAL WITH NO CHANGE IN LEVEL OF CONSCIOUSNESS. GCD=15. PEARLA. 3MM. SHE STATED THAT HER HEAD AND NECK HURT. NO BLEEDING. RESPIRATIONS WITH EASE. CERVICAL COLLAR APPLIED TO IMMOBILIZE HER NECK. HAND SLOWLY ADJUSTED SO SHE WAS NOT LAYING ON IT. POSITION MAINTAINED WITH SLIGHT ADJUSTMENT TO POSITION HER FOR COMFORT AND EASE OF BREATHING, VIA LOG ROLLING BY MULTIPLE STAFF, UNTIL EMERGENCY SERVICES ARRIVED AND TRANSPORTED HER TO ER FOR EVALUATION. MECHANICAL LIFT IMMEDIATELY INSPECTED BY DNS WITH NOTHING UNUSUAL NOTED. PLACED ON LOCKOUT/TAG OUT AND MOVED OUT OF ACCESS FOR USE; MAINTENANCE NOTIFIED TO INSPECT IT NEXT MORNING. INVESTIGATION STATED IN THE CAUSE OF THE FALL, INCLUDING INTERVIEWS, INSPECTION, ETC. ED AND DNS WAS PRESENT; (B)(6) NOTIFIED. BOTH AIDS STATE THAT ALL FOUR HOYER SLING STRAPS WERE IN PLACE CORRECTLY; THAT THEY WERE INSIDE THE HOOK AND UNDERNEATH THE SMALL METAL PIECE THAT PREVENTS THE STRAPS FROM COMING OFF THE HOOK. THEY NOTED THAT THEY HAD LIFTED HER WITH THAT HOYER AND SLING ABOVE HER BED AND THEN ACROSS APPROXIMATELY 6 FEET OVER TO HER RECLINER WHEN SHE FELL. THE STRAPS ON THE SLING HAD BEEN INSPECTED AFTER THE FALL AND WERE NOTED TO BE INTACT AND IN GOOD CONDITION. MAINTENANCE COMPLETED AN INSPECTION PER POLICY THE NEXT MORNING AND THE LIFT WAS IN GOOD SHAPE. FURTHER INVESTIGATION CONTINUES INCLUDING RE-ENACTMENT. ALL CNA'S WILL HAVE THEIR HOYER LIFT TRANSFER COMPETENCY REDONE, INCLUDING THE TWO INVOLVED. THE RESIDENT RETURNED TO (B)(6) THIS SAME DATE, WITH NO FRACTURES OR INJURY EXCEPT BRUISING ON RIGHT FOREHEAD/EYEBROW AREA. NEURO CHECKS CONTINUE AND WNL. SHE DENIED FEELING FEARFUL OF BEING TRANSFERRED VIA HOYER AND HAS DONE SO WITHOUT ANY ISSUES SINCE.