Failure to Address ADL and Transfer Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all activities of daily living (ADL) needs for two residents. One resident with cerebral palsy, who was dependent on staff for mobility and transfers and required assistance with all ADL tasks except eating, did not have a care plan that addressed his needs for transfers, bathing, and personal and oral hygiene. Although his care plan addressed limited physical mobility, it omitted specific interventions for his ADL care needs. Interviews with the resident and staff confirmed that he required substantial assistance and the use of a mechanical lift for transfers, but these needs were not reflected in his care plan. The omission was attributed to the absence of a dedicated MDS Coordinator at the time. Another resident with a right below-knee amputation, who required substantial assistance for transfers, also had a care plan that did not reflect his need for transfer assistance. The Regional MDS Consultant acknowledged that the transfer status was overlooked due to a personal emergency affecting MDS staff during the care plan's initiation. Both the consultant and the administrator confirmed that the care plans should have included these essential details to guide staff in providing appropriate care.