Failure to Provide Consistent ADL Assistance and Safe Transfers
Penalty
Summary
A deficiency occurred when a dependent resident with a history of respiratory failure, chronic pain, lumbar spinal fusion, and cervical spine surgery did not consistently receive assistance with activities of daily living (ADLs), specifically bathing and safe transfers. Documentation showed that the resident refused a shower on one occasion and received only one shower during a multi-week period, with other scheduled showers not attempted or documented. The resident's care plan required showers on specific days and one-person assistance with transfers, but staff failed to follow this schedule and did not consistently document refusals or communicate missed showers to nursing staff. Multiple staff interviews revealed a lack of a system to track missed showers, inconsistent documentation, and poor communication between CNAs and nursing regarding ADL care. Additionally, the resident reported pain after being transferred by a CNA using a bear hug technique, which was contrary to facility policy and the resident's care plan, especially given the resident's spinal history. Staff interviews confirmed that bear hug transfers were not permitted and that the resident's transfer needs were subject to frequent updates by therapy, requiring staff to review care plans regularly. Some staff were unaware of the resident's medical history and the risks associated with improper transfer methods. The Director of Nursing Services acknowledged that staff were expected to follow care plans for both transfers and scheduled showers, and that nurses should be tracking the completion of these tasks.