The Minnesota Department of Health (MDH) substantiated a finding of neglect after investigating an allegation under the Minnesota Reporting of Maltreatment of Vulnerable Adults Act. The investigation was concluded on December 11, 2025.
The allegation involved a resident who was injured during a transfer using a full-body mechanical Hoyer lift. According to the investigation, two staff members failed to properly secure the lift sling before initiating the transfer. As a result, the resident fell from the sling and sustained a femur fracture requiring surgical repair and hospitalization.
MDH determined that neglect was substantiated and that the two staff members involved were individually responsible for the maltreatment. Video footage reviewed during the investigation showed that the sling loop was not properly connected to the hook of the Hoyer lift spreader bar prior to moving the resident. During the transfer, the sling loop detached from the hook, causing the resident to fall to the floor from a suspended height of approximately three to four feet.
Following the fall, the resident was transferred to the emergency department, where the femur fracture was identified. The resident required surgical intervention and hospitalization as a result of the injury.
Compliance Perspective
Issue
Failure to ensure that residents are transferred safely using mechanical lifts, including properly securing lift slings and following care plan instructions, can result in serious injury and may be considered neglect and substandard care under state and federal regulations. Facilities must also ensure that all incidents, including falls or injuries during transfers, are reported promptly in accordance with regulatory requirements.
Discussion Points
- Review policies and procedures for mechanical lift use and resident transfers to ensure they include requirements for securing slings, following care plans, and verifying safety prior to moving residents. Also review reporting procedures to ensure incidents and injuries are reported promptly and appropriately. Guidance from an experienced healthcare consultant can help identify gaps and strengthen policies to reduce risk.
- Provide training for staff on safe use of mechanical lifts, including proper sling attachment, transfer techniques, and following residents’ care plan instructions. Training should also cover recognizing high-risk situations, reporting requirements for incidents, and preventing resident harm. Med-Net Academy offers clinical competencies for Hoyer Lifts and Mechanical Lifts. The competencies are adapted for the long-term post-acute and residential care/assisted living sectors and provide an evaluation of clinical competence.
- Periodically audit resident transfers, care plan compliance, and incident reports to ensure staff are following established procedures and that reporting requirements are met. Engaging an external reviewer or consultant can provide objective assessment and targeted recommendations to strengthen internal oversight and reduce the risk of resident injury.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*