Failure to Update Care Plan After Resident Readmission with New Transfer Needs
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for a resident upon readmission after the resident sustained a facility-acquired right femur fracture due to a fall. The resident, who had diagnoses including COPD, depression, and benign paroxysmal vertigo, was previously identified as a fall risk and had interventions in place such as calling for assistance when dizzy and using a call bell. After the fall, which occurred when the resident missed the wheelchair while attempting to sit, the RCP was updated to include use of a gait belt and instructing the resident to feel for wheelchair arms before sitting. However, following the resident's return from the hospital after surgery, new physician and therapy orders specified non-weight bearing status and transfer with a mechanical lift and assistance of two staff, but these changes were not reflected in the RCP or the Resident Care Card (RCC) in a timely manner. Staff interviews revealed confusion regarding the resident's current transfer status, with some staff relying on outdated RCC information and awaiting clarification before providing care. The facility's care planning policy required that care plans and care cards be updated as needed to reflect changes in the resident's status, but this was not done promptly after the resident's readmission and change in transfer needs. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which confirmed that the care plan and RCC did not direct staff to the updated transfer requirements following the resident's injury and hospital stay.