Failure to Include Transfer Assistance in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed a resident's need for transfer assistance as identified in her assessments and physician orders. The facility's policy required that residents needing extensive or total assistance with transfers be moved using a mechanical lift with two trained staff members. The resident in question was admitted with a diagnosis of muscle weakness and was assessed as dependent for all activities of daily living, including transfers, requiring a mechanical lift and two staff for assistance. Physician orders specified bed rest with turns every hour and no independent transfers. Despite these documented needs and orders, the resident's care plan did not include interventions specifying the requirement for two staff members or the use of a mechanical lift for transfers. This omission was confirmed during an interview with the Administrator, who acknowledged that the care plan should have addressed these specific transfer needs.