Failure to Develop Care Plan for 2-Person Transfer Assist
Penalty
Summary
Facility staff failed to develop a care plan that addressed a resident's need for a 2-person physical assist during transfers from wheelchair to bed. The resident, who had diagnoses including unspecified dementia, chronic atrial fibrillation, and muscle weakness, was assessed in the State Minimum Data Set (MDS) as requiring extensive assistance from two staff members for transfers. However, a review of the resident's care plan revealed no documented evidence specifying this requirement for a 2-person assist during transfers. An incident occurred in which a nursing assistant, after transferring the resident to bed, observed bleeding from the resident's mouth and nose, and a hematoma on the right lower leg. Staff interviews confirmed that the MDS assessment indicated a need for a 2-person assist, but the care plan did not reflect this. The Director of Nursing referenced physical therapy notes suggesting a one-person assist but acknowledged that a significant change MDS assessment had not been completed.