Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including acute respiratory failure, dementia, and muscle weakness, was not transferred according to her care plan. The care plan specified that the resident required a mechanical lift with two-person staff assistance for transfers due to her mobility limitations and dependence on assistive devices. However, during an observed transfer, two CNAs used a gait belt instead of the mechanical lift because a mechanical lift sling could not be located. The mechanical lift was present in the room, but the necessary sling was missing, leading staff to proceed with a manual transfer using a gait belt. Interviews with the involved CNAs confirmed that the resident was typically transferred with a mechanical lift, but due to the unavailability of a sling, they used a gait belt for the transfer. One CNA reported the deviation from the care plan to the charge nurse. The physical therapist noted that the resident's ability to transfer could vary depending on her anxiety or pain levels, but at the time of the incident, the care plan still required a mechanical lift. The facility administrator and DON acknowledged the risk associated with not following the care plan and stated there was no policy in place regarding this situation.