Failure to Follow Care Plan for Safe Resident Transfer
Penalty
Summary
A deficiency occurred when the facility failed to implement care planned transfer interventions for a resident with a right leg amputation who required two-person assistance with a mechanical lift for transfers from bed to a shower chair. Despite the care plan in place, the resident was transferred by a single CNA without the use of a mechanical lift, contrary to the documented requirements. This resulted in the resident experiencing a fall during the transfer process. Interviews revealed that the CNA acted based on the resident's statement that they no longer needed the mechanical lift and only required assistance from one staff member, as the resident was working with therapy on slide board transfers. However, the care plan at the time of the incident still required a two-person mechanical lift transfer, and staff were expected to review and follow the care plan. The Director of Nursing Services acknowledged that the care plan was not followed in this instance.