Failure to Develop and Implement Comprehensive Care Plan for Safe Transfers
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed the individualized needs and interventions for safe transfers for one resident. The resident, who was admitted with chronic kidney disease and an anxiety disorder, had a physician's order requiring the assistance of two staff members for transfers using a standing lift. Despite this order, there was an incident where two staff members manually transferred the resident to bed without the use of the standing lift, which was not in accordance with the care plan or physician's order. The resident, who was moderately cognitively impaired, experienced significant distress during the manual transfer and bit a nurse aide as a result. The incident was documented in a progress note, and the resident later explained that she was upset and frightened by the way she was transferred, as it deviated from the usual method involving the standing lift. Staff interviews confirmed that the manual transfer occurred and that the resident became anxious during the process. At the time of the incident, the resident's care plan did not identify her anxiety regarding transfers nor did it include the option for a manual two-person assist. The care plan was only updated after surveyor inquiries to reflect the resident's anxiety and to specify the appropriate transfer methods. Prior to this update, staff were expected to follow the physician's orders and the individualized plan of care, but the plan did not adequately address the resident's specific needs related to transfers.
Plan Of Correction
Resident 22's Transfer Care Plan was updated with individualized needs on. To identify like residents, a facility audit was completed by the DON/designee to identify any residents using a stand lift that have associated anxiety or behaviors. Care plans were updated to reflect individualized preferences for alternative safe transfers, other than facility policy to utilize Hoyer lift. To prevent reoccurrence, the DON/designee will educate licensed nursing on updating resident care plans with individualized preferences as they occur. To monitor and maintain compliance, the DON/designee will audit residents with new orders for stand lift/Hoyer lift, with associated anxiety or behaviors requiring individualized needs related to transfers, and update care plans as needed weekly x 4 and monthly x 2. Results will be reviewed at QAPI.