Transferring patients who are unable to do so themselves is not easy.
Especially when the patient is unable to help with the transfer because of his or her medical condition such as paralysis, a broken arm or leg, obesity or confusion, to name a few examples.
Usually one or two healthcare providers personally do the transfer. However, sometimes transferring patients involves the use of patient care equipment, such as a Hoyer lift.
Despite the many positive aspects of using lifting devices, in the following case, the transfer of a patient from her geri-chair to her bed using a Hoyer sling lift went very wrong.
Testimony and evidence presented at trial
An 84-year-old patient was transferred from a hospital to the nursing home. She had osteoarthritis and osteoporosis, which required her to be bed bound and dependent on nursing staff and others in the home to transfer her in and out of bed.
The patient’s care plan indicated she was at risk for falls and injuries when assisted with mobility and when transferred. A Hoyer (sling) lift and a geri-chair were required equipment.
In addition, the care plan specified that transferring patients required a two-or-more-person “physical assist” and the use of a sling lift.
One afternoon, the patient was being transferred from her geri-chair to her bed and she fell to the floor with the lift falling on her. She was then transferred from the floor to her bed.
This incident was documented in the patient’s chart, which indicated that she fell from the Hoyer lift that the doctor had been notified, and that the resident was taken to the hospital.
The ED and hospital notes contained more details. The ER notes detailed that the resident fell from the Hoyer lift approximately three feet. The nursing notes specified the patient arrived by EMS to the hospital with a complaint of a faulty Hoyer lift and “being struck by part of machinery.”
The note went on to state that the patient had multiple skin tear to her arms, which were dressed with steri-strips.
Less than two hours after being admitted to the hospital, the patient died. An autopsy was done but did not list a cause of death. The death certificate listed the cause of the patient’s accidental death as “blunt trauma of torso and extremities.”
Legal proceedings follow
The patient’s family filed a suit against the nursing home alleging its negligence caused the patient’s injury and death. The nursing home filed several motions in response to the suit, including a motion to dismiss the lawsuit. The trial court denied all of the nursing home’s motions.
The nursing home filed an appeal of the denial of its Motion to Dismiss. The appeals court denied the basis of the appeal and sent the case back to the trial court.
The nursing home objected to the filing of the family’s (plaintiff’s) amended complaint and a second and third amended expert report concerning the negligence of the nursing home.
The expert report identified that the breach of the standard of care of the nursing home was that only one staff person was present at the time of the transfer when two were required.
The nursing home filed another Motion to Dismiss, alleging that the expert witness’ report was not adequate. The trial court granted its motion. The family appealed that decision.
The appellate court’s decision
The court carefully analyzed the law and the evidence presented in the trial court. The expert’s report detailed at length the proper manner in which an individual should be transferred with a sling like device. Based on the evidence presented, the appellate court ruled the presence of only one staff member transferring the resident caused her “fall, injuries and death.”
Implications for your practice
If part of your nursing practice involves the use of lift equipment when transferring patients in a hospital or nursing home, it is important to:
- Be oriented to the proper use of the equipment.
- Complete training on the use of the equipment so you are competent to use it with patients.
- Regularly re-train on the equipment’s use.
- Continually read/learn about the lift devices.
- Never cut corners by substituting your own decisions about proper use of equipment.
- If a lift device is not working properly, notify your nurse manager and document that notification on the proper forms used by your facility and in the patient’s medical record.
- Inspect any sling used with your lift device for tears or holes.
- If you are concerned that a lift device for transferring patients in some way creates a risk to the patient, or to you (e.g., patient is too heavy, lift is not adequately positioned), notify your nurse manager and document that notification on the proper forms used by your facility.
Take these courses to learn more about protecting patients and yourself:
National Patient Safety Goals – Nursing
(1 contact hr)
This course covers the 2019 National Patient Safety Goals for nursing staff in the hospital setting.
Everyday Ethics for Nurses
(7.3 contact hrs)
This course provides an overview of bioethics as it applies to healthcare and nursing in the U.S. It shows how ethics functions within nursing and on a hospital-wide, interdisciplinary ethics committee. The course explains the elements of ethical decision-making as they apply both to the care of patients and to ethics committees. The course concludes with a look at the ethical challenges involved in physician-assisted suicide, organ transplantation, and genetic testing.
Protect Yourself: Know Your Nurse Practice Act
(1 contact hr)
Nurses have an obligation to keep abreast of current issues related to the regulation of the practice of nursing not only in their respective states but also across the nation. Nurses have a duty to patients to practice in a safe, competent, and responsible manner. This requires nurse licensees to practice in conformity with their state statutes and regulations. This course outlines information about nurse practice acts and how they affect nursing practice.