Failure to Revise and Implement Accurate Care Plan for Resident Transfer Needs
Penalty
Summary
The facility failed to revise and implement an accurate care plan for one resident following changes in the resident's transfer needs. The resident, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity, was initially care planned for transfers with assistance from two staff members using a walker and gait belt. However, after being discharged from physical therapy, the resident's transfer status had improved to require only one staff member with a gait belt and walker. Despite this change, the care plan was not updated to reflect the new level of assistance needed. On the day of the incident, the resident experienced muscle jerks and dizziness while preparing to transfer from the bed to a wheelchair. The CNA assisting the resident followed the resident's preference for the gait belt placement and attempted to readjust the belt when the resident reported nausea. During this process, the resident became anxious, stood up, and fell forward onto the floor. Multiple staff responded, assessed the resident, and used a mechanical lift to transfer the resident to a wheelchair. The resident initially complained of toe pain, and later reported ankle pain, prompting a transfer to the hospital for further evaluation. Interviews with staff confirmed that the resident was being assisted by only one staff member during transfers, consistent with the updated physical therapy recommendations but inconsistent with the care plan documentation, which still indicated assistance from two staff members. The Director of Nursing acknowledged that the care plan was not correct and should have been updated to reflect the resident's current needs. Facility policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, but this was not done in this case.