Failure to Implement Physician's Order for Resident Transfer to Chair
Penalty
Summary
A deficiency occurred when staff failed to implement a physician's order for a resident to be transferred to a chair three times a week during the day shift. Despite the resident being cognitively intact and able to request assistance, staff did not respond to the resident's request to be gotten up to a chair during the observed period. The resident pressed the call light and directly asked a CNA for help, who stated they would return with assistance but did not follow through. Over a two-hour and seventeen-minute observation period, no staff entered the room to assist the resident, and the resident remained in bed throughout. Record reviews confirmed that the resident was dependent on staff for all transfers and required a two-person assist with a mechanical lift, as documented in the care plan and physician orders. However, there was no documentation of the resident being transferred to a chair as ordered, nor was this intervention included in the Kardex. Interviews with staff revealed a lack of training on repositioning and inconsistent documentation practices regarding position changes and transfers. Staff indicated that residents should be turned every two hours and assisted to a chair upon request, but these practices were not consistently followed or documented for this resident. Family interviews corroborated that the resident was not routinely gotten up to a chair as ordered, and concerns were raised about the resident being left on their back for extended periods. Facility leadership acknowledged that residents should not remain in one position for hours and that failure to assist with transfers could lead to negative outcomes. Facility policies reviewed emphasized the importance of frequent repositioning and activity to prevent pressure ulcers, but these were not adhered to in the resident's care.