Failure to Develop and Implement Care Plans for Specialized Equipment Use
Penalty
Summary
The facility failed to develop and implement individualized care plans for residents requiring specialized equipment, specifically for the use of Hoyer lifts and Geri-chairs. One resident, who had multiple complex medical diagnoses including metabolic encephalopathy, sepsis, chronic systolic heart failure, and cerebral palsy, required assistance with transfers and had been using a Hoyer lift since admission. Despite this, the resident’s care plan did not include the use of the Hoyer lift as an intervention. During observation, a CNA was seen transferring the resident alone with the Hoyer lift, contrary to facility policy requiring two staff members for such transfers. The CNA stated she was aware of the policy but proceeded alone due to lack of available assistance after multiple call light requests. Two other residents were observed using Geri-chairs without any documented care plan, physician order, or therapy evaluation supporting their use. One resident was found in a Geri-chair with a Hoyer lift sling underneath, and staff interviews revealed uncertainty about who authorized the use of the Geri-chair. The resident’s medical record lacked any therapy evaluation or physician order for the Geri-chair, and subsequent therapy assessment recommended a wheelchair instead. Another resident was observed in a Geri-chair and expressed discomfort, stating a preference for a different seating position. Staff indicated the Geri-chair was used for safety due to fall risk and behavioral concerns, but again, there was no care plan, physician order, or therapy evaluation documented for this intervention. Interviews with nursing and therapy staff confirmed the absence of required documentation and care planning for the use of both the Hoyer lift and Geri-chairs. The DON and Risk Manager were unaware that Geri-chairs could be considered physical restraints and acknowledged the lack of documentation or rationale for their use. The deficiencies were identified through direct observation, record review, and staff interviews, revealing a systemic failure to ensure that residents’ needs for specialized equipment were properly assessed, documented, and incorporated into individualized care plans.