Failure to Update Care Plan for Resident Transfer Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, including hemiplegia, hemiparesis, cerebral infarction, and dementia. The resident's care plan inaccurately documented that only one person was required for transfers, despite multiple records and staff interviews confirming that the resident required a two-person mechanical lift transfer. The care plan had not been updated to reflect the resident's actual transfer needs, even though the resident's quarterly MDS assessment indicated substantial/maximal assistance was necessary. Interviews with CNAs and LVNs revealed that staff were aware of the need for a two-person mechanical lift transfer, but this information was often communicated verbally rather than through the care plan. Some staff relied on cheat sheets or verbal reports instead of reading the care plan, while others stated they would refer to the care plan if unsure about a resident's needs. The Director of Nursing acknowledged that the care plan was outdated and needed to be revised to prevent inappropriate transfers, as per facility policy requiring ongoing assessment and timely updates to care plans.