Failure to Support Resident Choice for Weekend Transfers
Penalty
Summary
The facility failed to honor and facilitate a resident's right to self-determination by not assisting a resident out of bed on weekends according to her preference. The resident, who had diagnoses including major depressive disorder, insomnia, weakness, constipation, and cerebral palsy, required extensive two-person assistance and a Hoyer lift for transfers. Documentation showed that on multiple weekends, the resident was not transferred out of bed, and there was no record of refusal or clinical reason for remaining in bed on those days. The care plan included interventions to encourage activity and participation in daily living, but these were not consistently implemented. Interviews with the resident and staff revealed that the resident wanted to get out of bed on weekends but was not assisted by staff, who cited reasons such as loose stools, diarrhea, or the resident's occasional refusal. However, there was no documentation to support that the resident refused or that clinical conditions prevented transfers on the specific dates in question. Staffing patterns on weekends were also noted, but the lack of documentation and failure to follow the resident's expressed preferences led to the deficiency.