Failure to Follow Care Plan for Dependent Transfer
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for one resident who required assistance with transfers. The resident, who had diagnoses including Parkinson's Disease, unspecified osteoarthritis, a history of falls, a left artificial knee joint, and a right below-knee amputation, was assessed as severely cognitively impaired and dependent for chair/bed transfers. The care plan specified that the resident required a Hoyer lift with two staff for all transfers. However, on the day in question, two CNAs who were unfamiliar with the resident's needs transferred her between bed and wheelchair using a draw sheet instead of the required Hoyer lift. Both CNAs confirmed in interviews that they did not check the resident's care plan or the electronic system to verify the required transfer method before performing the transfer. The Director of Nursing confirmed that the resident was not transferred according to her plan of care and that staff are expected to verify the required assistance level if they are unsure. The CNAs involved stated they should have checked the system or asked for guidance but did not do so prior to transferring the resident. This failure to follow the established care plan resulted in the resident not receiving care as planned for her specific needs.