Denton Nursing Rehab: Hoyer Lift Fall Injuries - MD
The resident, identified as Resident #11, required two staff members for all transfers according to facility care plans dating back to April 30, 2024. The resident was totally dependent on staff for all activities of daily living.
GNA #16 was working alone in the room when the incident occurred at the end of the day shift. According to witness accounts, the resident's leg hit the bed during the transfer, causing them to slide out of the sling and fall to the floor.
"When I went in there she was the only one in there when I walked in," said GNA #22, who heard a yell and responded to the scene. "All she said was that she was transferring [the resident] back into the bed and it was a split body sling, and [he/she] had fallen through it."
The resident was lying flat on their back when staff arrived. "The resident was saying that [he/she] was in pain," GNA #22 recalled. "I don't recall if [he/she] was crying but I do remember [him/her] saying [he/she] was in a lot of pain. There was a wound on [his/her] bottom and I believe it was bleeding after the fall."
It took four staff members to get the resident back into bed using the Hoyer lift. The resident continued expressing pain during the transfer back to bed.
LPN #15, the only nurse covering two units that day, was called to the scene. "I remember them coming to get me that [he/she] fell out of the Hoyer lift," the nurse said. "I called the doctor and 911 and had [him/her] sent to the hospital."
The facility was severely understaffed that day. Only three nursing assistants were working the day shift across multiple units, with each aide responsible for 15 to 16 residents. GNA #16 was assigned to both unit 300 and unit 400, creating a split assignment.
"I think we were short staffed that day. We worked short a lot," LPN #15 said. "It was so busy, crazy that day and I was the only nurse on those 2 hallways."
The understaffing forced dangerous shortcuts. "That is a lot for day shift because most of them are total care," explained GNA #22. "During that time the nurse would try her best to help with transfers or a unit manager or someone but if they were too busy I'd have to do it myself, especially if it were 3 of us having 15-16 residents a piece."
GNA #22 admitted that before this incident, single-person Hoyer transfers were common practice. "I can say sometimes I have transferred people by myself, but after that incident I have not transferred by myself using the Hoyer lift. Prior to the fall I would see other GNAs transferring with the Hoyer by themselves."
Staff #17, the facility's Director of Nursing at the time, confirmed the policy violation. "One of our aides was transferring [him/her] by herself without a second person and she said the leg hit the bed and the resident slid out of the sling and fell on the floor."
The sling itself was not defective. "It was the right size sling. It was [his/her] sling," Staff #17 noted.
The facility fired GNA #16 for the safety violation. "We let her go for transferring without a second person that resulted in the resident being hurt," Staff #17 said.
Physician #31, who treated the resident, called the incident "a big deal" and questioned why a single person was attempting the transfer.
The inspection revealed a pattern of unsafe practices driven by chronic understaffing. Nursing assistants regularly handled 15 to 16 residents each during day shifts, when most residents required total care. The facility's nursing schedule for December 16 documented only one licensed practical nurse and two nursing assistants covering unit 300, where the injured resident lived.
Federal inspectors found the facility failed to ensure residents were free from accidents and received adequate supervision during transfers. The violation resulted in actual harm to the resident, who required emergency medical treatment for injuries sustained in the fall.
The incident occurred despite clear care plan documentation requiring two-person assistance for all transfers using the Hoyer lift, a mechanical device designed to safely move residents who cannot bear weight or assist with transfers.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Denton Nursing and Rehab from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
DENTON NURSING AND REHAB in DENTON, MD was cited for violations during a health inspection on September 4, 2025.
The resident, identified as Resident #11, required two staff members for all transfers according to facility care plans dating back to April 30, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.