Failure to Update Care Plan for Correct Sling Size During Transfers
Penalty
Summary
The facility failed to update a resident's care plan and Kardex to accurately reflect the correct size sling required for mechanical lift transfers. The resident, who had diagnoses including dementia, obesity, lymphedema, dorsalgia, muscle weakness, rheumatoid arthritis, and limited mobility, was dependent on staff for all transfers. Although a Lift-Transfer Evaluation determined that the resident required a blue (extra large) sling based on weight and height, the care plan and Kardex continued to instruct staff to use a green (large) sling. Staff interviews confirmed that the blue sling was being used in practice, but the documentation had not been revised to match this change. The DON confirmed that the care plan and Kardex were not updated to reflect the current transfer method.