Failure to Update Care Plan After Change in Transfer Assistance
Penalty
Summary
The facility failed to update the care plan for one resident after her transfer assistance needs changed to require the use of a mechanical lift (EZ stand). The resident, who had no cognitive impairment and was dependent on staff for toileting and transfers, experienced a decline in mobility and began requiring mechanical lift assistance. Despite this change, her care plan and bedside Kardex continued to document the need for substantial assistance of two staff for transfers, without specifying the use of the EZ stand. Staff interviews revealed that the change in transfer method was communicated verbally between shifts rather than through formal care plan updates. Multiple staff members, including CNAs and the LPN, confirmed that the resident's transfer method had changed and that the care plan was not updated to reflect this. The DON acknowledged that care plans should be updated as needed and that staff rely on the Kardex and EHR for resident care information. The facility's policy required comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not followed in this instance, resulting in the care plan lacking documentation of the mechanical lift requirement.