Failure to Update Care Plan Following Change in Transfer Ability
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect the resident's current ability to transfer from a wheelchair to a bed. A facility-reported incident revealed that the resident sustained a hematoma of unknown origin to the left lower extremity, which the facility's investigation determined likely resulted from a difficult transfer. Interviews with staff confirmed that care plans are supposed to be updated when new physical therapy (PT) orders are received, but in this case, the care plan was not revised to reflect the resident's updated transfer status and abilities as documented in PT progress notes. The care plan continued to state that the resident could perform all transfers with assist of one, despite PT documentation indicating that transfer goals had been removed due to the resident's pain and unwillingness to work on transfers. No updates to the care plan regarding transfer status were found after the initial entry.