Failure to Update Care Plan for Resident Requiring Extensive Transfer Assistance
Penalty
Summary
The facility failed to review and revise the comprehensive, person-centered care plan for one resident who required assistance with transfers. Despite documentation and staff interviews indicating that the resident had progressed to needing extensive assistance and the use of a mechanical lift for transfers, the care plan continued to state that only limited assistance by one staff member was required. Observations confirmed the resident was using a mechanical lift with a blue sling and required two staff for transfers, as corroborated by a CNA who reported that the resident had not used the Stand Aid for several weeks. The resident's medical record reflected multiple diagnoses, including muscle weakness, difficulty walking, and unsteadiness, and the most recent MDS assessment showed memory impairment and a need for partial to moderate assistance with transfers. However, transfer documentation over a one-month period showed the resident required extensive assistance or was totally dependent for most transfers. The facility's policy required care plans to be updated by an interdisciplinary team after each assessment, but this was not done in this case, resulting in an inaccurate care plan that did not reflect the resident's current needs.