Failure to Follow Care Plan for Mechanical Lift Transfer Sling Size
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required transfers using a mechanical lift. According to the resident's most recent assessment and lift transfer evaluation, the resident was dependent on staff for transfers and required the use of a medium (purple) full body sling with the electric mechanical lift. The care plan and CNA Kardex both specified the use of a medium (purple) sling for all transfers, based on the manufacturer's guide and nursing assessment. Despite these documented requirements, observations on the day of the survey found the resident in a wheelchair with a large (green) sling underneath, which did not match the care plan instructions. Multiple CNAs interviewed confirmed that they determine sling size by the color indicated in the Kardex, but the resident was observed using the incorrect color and size. The Regional Administrator also confirmed during the review that the resident was not in the correct sling as per the plan of care.