Failure to Individualize and Update Transfer Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, resulting in unclear instructions for staff regarding the required level of assistance for transfers. For one resident with severe cognitive impairment, muscle weakness, and contractures, the care plan was not updated in a timely manner to specify the use of a mechanical lift with two staff members. Staff interviews revealed confusion and lack of clarity about whether one or two staff were needed for transfers, and an incident was observed where a CNA used a Hoyer lift alone, contrary to best practices and the resident's needs. The care plan was only revised after the incident to specify two-person assistance with a mechanical lift. For another resident with hemiplegia, muscle weakness, and a history of falls, the care plan and Kardex documentation were inconsistent regarding the number of staff required for transfers. The care plan included vague instructions such as "1-2 assist as needed" and did not clearly communicate the resident's current needs. Staff interviews indicated that CNAs were left to decide whether one or two staff should assist, based on their judgment rather than clear care plan directives. The resident reported using a sit-to-stand mechanical lift and being informed of a recent fall, but documentation did not specify the required assistance level. The facility's policy required care plans to be individualized, updated with changes in resident condition, and clearly communicated to all staff. However, the interdisciplinary team did not ensure that care plans were consistently revised or that staff were provided with clear, measurable actions for resident transfers. This lack of specificity and timely updating in care plans led to staff uncertainty and inconsistent care practices for residents requiring assistance with transfers.