Failure to Document Mechanical Lift Transfers in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents who required mechanical lift transfers. For the first resident, who had diagnoses including chronic obstructive pulmonary disease with acute exacerbation and morbid obesity, the care plan did not specify the need for transfer via mechanical lift, despite the resident being dependent on staff for transfers. Observation confirmed that staff transferred this resident using a mechanical lift, but this intervention was not documented in the care plan. Similarly, the second resident, diagnosed with vascular parkinsonism and vascular dementia and dependent on staff for all activities of daily living, had a care plan that only mentioned the use of mobility bars for repositioning in bed and encouragement to participate in care, without identifying the need for mechanical lift transfers. Observation also confirmed that this resident was transferred using a mechanical lift. Interviews with the MDS Coordinator and the DON confirmed that both residents required two-person assistance with transfers via mechanical lift, and acknowledged that the care plans did not reflect this requirement. The facility's policy requires the interdisciplinary team to develop care plans with measurable objectives and timeframes based on comprehensive assessments, but this was not followed for these residents. The lack of documentation in the care plans could result in staff not providing the required services during transfers, as the necessary interventions were not clearly identified.