Failure to Provide Timely Transfer Services
Penalty
Summary
The facility failed to provide necessary transfer services for a resident who required extensive assistance for activities of daily living. The resident, diagnosed with multiple sclerosis and atrial fibrillation, was admitted for long-term care and required a two-person assist for transfers out of bed. Despite being cognitively intact, as indicated by a BIMS score of 15, the resident experienced a significant delay in being transferred out of bed. On the day in question, the resident activated the call bell in the morning but was not assisted out of bed until 4:30 PM, despite her usual routine of being out of bed by lunchtime. The delay was corroborated by the resident's roommate, who also had a BIMS score of 15, confirming her cognitive intactness. The roommate verified that the resident typically gets out of bed by noon. An interview with a nurse aide revealed that the resident was washed and changed in the morning, but the aide could not explain the delay in transferring the resident. The resident mentioned that the lift used for her transfer sometimes did not work, causing further delays. This incident highlights the facility's failure to meet the requirement of providing necessary services for residents unable to carry out activities of daily living.
Plan Of Correction
The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiency (s) herein. To remain in compliance with all federal and state regulations, the facility has taken, and will take, the actions set forth in the following plan of correction. The following plan of correction constitutes the center's allegation of compliance. All alleged deficiencies cited have been, or will be corrected by the date or dates indicated. The facility is committed to taking all actions necessary to remain in substantial compliance with state and federal regulations. The plan of correction addresses our intention to promote care for our residents which enhances their dignity and is designed to meet their interests and promote the highest practicable level of physical, mental, and psychosocial well-being. Resident 23 got out of bed and had no ill effect for not getting out of bed at preferred time after miscommunication between resident and nurse aide. Aide thought resident wanted to stay in bed late. No other like residents. A comprehensive review of current residents will be completed to determine preferences on getting out of bed and to ensure they are getting out of bed as preferred. Director of nursing / Designee will educate nurse aides on Ftag 0677 ADL Care Provided for Dependent Residents, focusing on getting out of bed as preferred. Audits of 5 random residents will be completed by unit managers / designee per week for 4 weeks to ensure they are getting out of bed as preferred. Results of the audits will be reviewed by the QAPI committee for recommendations.