Failure to Update Care Plan for Resident's Transfer Status and Assistive Device Use
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect the resident's current transfer and ambulation status, as well as the use of assistive devices. The resident, who is cognitively intact, reported falling in the bathroom a few weeks prior, resulting in a broken tailbone. Following the fall, the resident began using a wheeled walker and received therapy. Despite this change, the care plan continued to state that the resident did not use any assistive devices for walking and required setup assistance for transfers, which was inconsistent with the resident's current independent status and use of a walker. Observations and interviews confirmed that the resident was independently transferring and ambulating with a wheeled walker, and staff acknowledged that the care plan had not been updated to reflect these changes. The MDS documented the resident as needing staff supervision or touch assistance, but both nursing and therapy staff confirmed the resident's independence and use of a walker, which began on 7/31/25. The care plan had not been revised to accurately document the resident's current needs and assistive device usage.