Failure to Update and Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to review and revise comprehensive care plans to accurately reflect the current status and needs of two residents. For one resident, staff were observed transferring the individual from a wheelchair to the bathroom using a sit-to-stand mechanical lift, while the care plan specified a pivot transfer with one staff assist using a gait belt. A staff nurse confirmed that the resident was being transferred with a sit-to-stand lift, indicating the care plan was not updated to match the resident's actual transfer method. For another resident who experienced a weight loss of more than 10% in one month, the care plan noted unplanned weight loss but did not specify the related factors, evidence, target weight range, or frequency of weighing, and lacked interventions and goals addressing the weight loss. These deficiencies limited staff communication and continuity of care for the affected residents.