| 6400.32(c) | Individual #1's right to not be neglected was violated. On 1/15/25, Staff #1 did not properly Individual #1 in a Hoyer lift while transitioning Individual #1 from the bathroom to the bedroom, resulting in Individual #1 falling out of the Hoyer lift onto the floor, hitting her face and head. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The target was fully trained on the proper use and procedures of a hoyer lift when transporting an individual prior to working alone with individual #1. Photos obtained by the investigator contradict the fact that the target states individual # was able to pull her knees up towards her chest and slide out of the middle of the sling pad of the hoyer lift. photos indicate that only one of the sling hooks by individual #1's legs were secured. According to the target's witness statement she had various issues occurring in her personal life that may had caused this human error. The target was suspended and subsequently did participate in the investigation but due to various other personnel issues that the target was involved in, she was terminated from her employment at St. Joseph's center before ever returning to work. Documentation will be provided on proof of hoyer lift training. |
02/27/2025
| Implemented |
| 6400.32(d) | Individual #1's right to be treated with dignity and respect was violated. On 1/25/25, Staff #1 was transitioning Individual #1 in a Hoyer lift from the bathroom to Individual #1's bedroom while naked. Staff #1 did not ensure Individual #1's dignity while transitioning the individual in the Hoyer lift. The distance from the bathroom to the bedroom is approximately 12-15 feet. | An individual shall be treated with dignity and respect. | Individual #1 utilizes a hoyer lift in order to get from position to position throughout her home. Individual #1 prefers a whirl pool or bath for her bathing routine. Due to physical limitations in her home, there is not a changing table in the bathroom where the whirl pool tub is located. When individual #1 is finished with her bath, staff cover her in towels and then utilize the hoyer lift to get her out of the tub, into her room, and onto her bed to get dressed. At the time of the incident when individual #1 fell out of the hoyer lift she did in fact have towels covering her to protect her dignity maintain respect. Pictures obtained by the investigator during the investigation show a towel covering Individual #1 with her legs below. A witness statement from the target was obtained in which she stated that individual was then dressed on the floor and then covered with a blanket due to her hypothermia diagnosis and so as not to move her in the event there was a serious injury. Individual #1 remained covered throughout the incident and until emergency services arrived. |
01/27/2025
| Implemented |