Failure to Document Transfer Interventions in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plan interventions for transfers for two residents who were dependent on staff assistance for mobility. Both residents had documented needs for substantial to maximal assistance with transfers, as indicated by their assessments and physical therapy evaluations. Despite this, their care plans did not include specific interventions for transferring, such as the use of a slider board, gait belt, or sit-to-stand lift, even though these methods were observed being used by staff during transfers. Staff interviews confirmed that these transfer methods were consistently used, but not documented in the residents' care plans. The deficiency was identified through observations, record reviews, and staff and resident interviews. The MDS coordinator and DON both acknowledged that interventions for transfers should have been documented in the care plans, but were not. The residents involved had significant physical limitations, including one with an acquired absence of the right leg below the knee and another with Parkinson's disease and schizophrenia, both requiring assistance for safe transfers. The lack of documented interventions in the care plans was contrary to facility policy and regulatory requirements for comprehensive, person-centered care planning.