Failure to Update Care Plan After Change in Transfer Needs
Penalty
Summary
The facility failed to revise the care plan for a resident who no longer required the use of a mechanical lift for transfers. Despite the resident's progress in therapy, which resulted in discharge at contact guard assist level and no longer needing a lift, the care plan continued to list interventions for a Hoyer Total Lift and related equipment. Multiple staff interviews confirmed that the resident was independent with transfers, requiring only assistance from one staff member, and that there were no current orders for a mechanical lift. However, the care plan had not been updated to reflect these changes, and the last lift evaluation on file was outdated. The deficiency was identified through observations, interviews, and record reviews, which revealed that the care plan did not accurately reflect the resident's current needs and abilities. The resident, who was cognitively intact and had a history of seizures, anxiety disorder, delusional disorders, and traumatic brain injury, was able to transfer with minimal assistance and did not require a lift. Facility staff, including nursing and therapy, confirmed the discrepancy between the resident's current status and the care plan documentation.