Failure to Implement Physician-Ordered Transfers in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included all ordered care for a resident who was dependent on staff for transfers and required to be up in a wheelchair three times a week, as ordered by the physician. Observations revealed that despite the resident's request to be transferred to a chair, staff did not provide the required assistance during the observed period. The care plan and Kardex did not include the physician's order for the resident to be up in a wheelchair three times weekly, and there was no documentation of this intervention being carried out. Interviews with staff confirmed that they relied on the care plan and Kardex for resident care instructions, but these documents lacked the necessary information regarding the transfer order. The resident was cognitively intact and required maximum to total assistance for most activities of daily living, including transfers, as documented in the Minimum Data Set. Family members reported that the resident was not being transferred to a chair as ordered and expressed concerns about the resident being left in bed for extended periods. Staff interviews indicated a lack of training on repositioning and an absence of documentation or interventions in the care plan to address the physician's order for regular transfers to a chair. This failure to include and implement the ordered care in the resident's care plan led to the deficiency.