According to the report, when interviewed facility leadership stated all staff including AP1 and AP2 were trained and competency tested on using the Hoyer lifts at the time of hire and in November 2025, prior to the incident, when the new Hoyer lifts were implemented by the facility. Nursing leadership stated when she observed the video from the incident it showed the resident was not properly connected to the Hoyer prior to staff moving the resident. Nursing leadership stated AP1 and AP2 failed to ensure the sling strap loop was all the way into the hook before moving the resident. Nursing leadership stated both AP1 and AP2 should have double checked before moving the resident. During a previous federal investigation interview, after watching the video from the fall incident, nursing leadership stated AP1 and AP2 did not following manufactures instructions for proper sling attachment during the transfer.

Nursing leadership stated AP1 and AP2 incorrectly placed the right lower sling loop at the top of the hook instead of inside the lower part of the hook resulting in the loop detaching from the hook, which caused the resident to fall to the floor. When interviewed the lift manufacturer customer service representative stated staff should ensure the sling loops are properly connected into the hook of the spreader bar, once attached, they should make sure it is correctly secured. The representative stated it would not be safe to move the resident if the loop was on top of the hook and indicated it would not be connected properly or fully secure in the loop and could fall off the hook.

When interviewed AP1 stated the night of the incident they were short staffed causing her to be under significant stress which she felt contributed to her being distracted the night of the incident. However, a review of the facility staffing schedules from the day of the incident and email communication with facility leadership failed to indicate there were any staffing issues or shortages the day of the incident as indicated by AP1. AP1 stated she connected the sling loops to the hooks of the Hoyer and lifted the resident off the bed then pulled him away from the bed. AP1 stated she normally watched all 4 loops and hooks like a hawk when a resident was first lifted off the bed to make sure things were connected properly and everything looked ok before moving a resident, but admitted she did not do so at the time of the incident.

AP1 stated AP2 was there as the second pair of eyes but AP2 also did not notice the loop was not connected properly to the hook. AP1 stated she was watching the resident, but did not ensure the sling loops were securely connected to the Hoyer before moving the resident. AP2 stated the day of the incident she helped hook the resident sling loops up to the Hoyer and indicated she was looking at the shower chair and moved to bring the chair closer when the sling loop fell off and the resident fell on the floor. AP2 stated she did not recall checking to ensure the loops were connected properly to the Hoyer hooks, and indicated she should have checked. When interviewed the resident’s family member stated the video from the incident it showed the loop of the sling was placed on top of the hook and not connected to the Hoyer properly. The family member stated although the resident physically had returned to his baseline prior to the incident, he was traumatized by the pain he experienced as a result of his injury and had difficulty trusting caregivers following the incident.

In conclusion, the Minnesota Department of Health determined neglect was substantiated.