Failure to Follow Care Plan for Safe Resident Transfers
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with Alzheimer's disease and kidney disease, who was dependent on staff for all activities of daily living and required two-person assistance with a gait belt for transfers. The care directive specified the use of a sit-to-stand device with two staff in the morning and two staff with a gait belt for all other transfers. Despite these requirements, a nursing assistant transferred the resident without a second staff member and did not use a gait belt, contrary to the established care plan. As a result of this failure, the resident fell in the bathroom, sustaining a head laceration that required eight staples and multiple bruises. The facility's investigation confirmed that the root cause of the fall was the staff member's noncompliance with the care plan, specifically the lack of a second staff person and the absence of a gait belt during the transfer. Staff interviews corroborated the resident's need for two-person assistance and the use of a gait belt, and it was noted that the resident could be resistive during transfers, further emphasizing the importance of following the care plan.