Failure to Update and Implement Resident Transfer Care Plan
Penalty
Summary
The facility failed to ensure that care plans accurately reflected a resident's current care needs for safe transfer status, specifically regarding the use of a mechanical lift. A certified nursing assistant (CNA) assisted a resident, who was recovering from a hip fracture, to stand and transfer to the toilet without applying a gait belt or using a mechanical lift, despite the resident requiring verbal and physical cueing. The CNA stated that they followed care card instructions and were aware of the resident's recent hip fracture. Another CNA reported transferring the same resident from bed to wheelchair without any equipment or gait belt, recalling the resident as a stand and pivot with one-person assist for transfers. The restorative nurse confirmed that prior to the resident's fall, the transfer status was stand and pivot with one assist, but following the hip fracture, the resident should have been transferred using a mechanical lift. The care plan, dated after the hip fracture, indicated the need for two staff and a full-body mechanical lift for transfers, but did not document the previous transfer status or the use of a gait belt. The MDS assessment identified the resident as using a walker and requiring partial to moderate staff assistance for transfers. These inconsistencies between the care plan, staff actions, and resident needs led to the deficiency.