Failure to Implement and Document Care Plan Interventions for Transfers and Oxygen Therapy
Penalty
Summary
A deficiency was identified when a Certified Nurses Aide (CNA) transferred a resident from bed to wheelchair using a mechanical lift without the required assistance of a second staff member. The CNA stated she performed the transfer alone because she felt capable and the resident trusted her, despite facility policy and the resident's care plan specifying that two staff are required for mechanical lift transfers. The Head Nurse confirmed that this protocol is in place for resident safety and is clearly documented in the care plan accessible to all staff. Additionally, another resident receiving hospice services and with a physician's order for oxygen use as needed did not have any interventions related to oxygen therapy documented in her care plan. The Director of Nursing reviewed the care plan and confirmed the absence of any mention of oxygen use, despite the resident having an active order for titrated oxygen per nasal cannula as needed. The facility's policy on oxygen administration requires review of the care plan for special needs, which was not reflected in the resident's documentation.