Failure to Document and Communicate Resident Transfer Needs on Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan that included the minimum healthcare information necessary to provide effective, person-centered care for a newly admitted resident. Specifically, the baseline care plan and the bedside Kardex did not document the resident's transfer needs, despite the resident being dependent and requiring a total lift for transfers. This omission was confirmed through staff interviews and record reviews, which showed that the resident's transfer status was not assessed or communicated to staff at the time of admission. As a result of this incomplete documentation, the resident's transfer needs were not identified or communicated, leading to an incident where the resident sustained a laceration during a transfer from bed to chair. The injury was classified as a trauma injury and measured 4.5 cm by 5.5 cm by 0.2 cm. Staff interviews confirmed that the information regarding the resident's dependency and need for a total lift was not available on the Kardex or baseline care plan, and staff should have consulted the nurse supervisor for clarification.