The incident occurred at Community Hospital of San Bernardino DP SNF, where staff violated the facility's own Safe Patient Handling and Mobility Program policy requiring proper equipment inspection and secure attachment before lifting patients.
The Clinical Director admitted during an October 10 interview that "the facility did not follow the policy and procedure." The facility's written policy, revised in July 2023, explicitly requires staff to ensure "lifting accessories are not damaged" and "correctly and securely applied to the patient, so that no personal injury can occur."
Federal inspectors found that nursing staff failed to properly hook the C clasp attachment that connects the Hoyer lift's scale portion to the lifting strap. When the connection failed during the transfer, the resident fell.
The Administrator defended the equipment itself during a phone interview six days after the inspection. "There were no issues with the Hoyer lift machine, and it was in working condition prior to Resident 1's fall incident," the Administrator stated. Instead, the Administrator blamed nursing staff, saying they "were at fault and should have been more careful regarding proper Hoyer lift usage and safety to prevent similar errors in the future."
But maintenance records revealed potential equipment problems. MS 2, apparently a maintenance supervisor, told inspectors during an October 17 phone interview that the Hoyer lift was last inspected in October 2024. The equipment was scheduled for annual inspections, meaning it would be "due for maintenance again by the end of October 2025."
MS 2 offered a technical explanation for the equipment failure: "The separation of the attaching C clasp on the scale portion of the Hoyer lift from the C clasp of the lifting strap was probably caused by whoever did it didn't hook it up properly. They probably didn't notice it wasn't seated properly."
The maintenance supervisor expressed confusion about how such a failure could occur with properly functioning equipment. "I don't know how else it would fall like that. It doesn't make sense," MS 2 said.
Hoyer lifts are mechanical devices designed to safely transfer patients who cannot move independently. The equipment uses fabric slings attached to a hydraulic or electric lift mechanism. The C clasp connections are critical safety components that must be properly secured to prevent falls during transfers.
The facility's policy explicitly outlined safety requirements that staff ignored. Before any lift, the policy required staff to verify "the lifting accessories is selected appropriately in terms of type, size, material and design with regard to the patient's needs" and ensure "lifting accessories are not damaged."
The policy also mandated that "the lifting accessory is correctly applied to the lifting equipment" and "correctly and securely applied to the patient, so that no personal injury can occur."
Federal inspectors classified the violation as causing "actual harm" to residents, though they found it affected "few" patients. The inspection was conducted in response to a complaint about the facility.
The timing of the incident raised additional concerns. With the Hoyer lift due for its annual maintenance inspection by the end of October 2025, the equipment failure occurred just as the machine approached its scheduled service date.
The Administrator's response focused entirely on staff blame while acknowledging no equipment defects. This contradicted the maintenance supervisor's technical analysis suggesting the C clasp separation indicated either improper attachment by staff or potential equipment wear that made proper seating difficult to achieve or maintain.
The Clinical Director's admission that the facility failed to follow its own safety policies highlighted a systemic breakdown in patient protection protocols. The policy was designed specifically to prevent the type of injury that occurred, yet staff violated multiple safety requirements during the transfer.
The incident exposed gaps between the facility's written safety commitments and actual practice. While the facility maintained detailed policies requiring careful equipment inspection and proper attachment procedures, staff failed to implement these basic safety measures during patient care.
The injured resident's outcome remained unclear from the inspection report, though federal inspectors determined the incident caused actual harm requiring regulatory intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Community Hospital of San Bernardino Dp Snf from 2025-10-10 including all violations, facility responses, and corrective action plans.
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