Failure to Implement Consistent, Comprehensive Care Plans for Safe Transfers
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for two residents with identified needs for safe transferring and fall prevention. For one resident with type II diabetes and chronic kidney disease, there were multiple conflicting interventions documented regarding transfer assistance, including discrepancies between the care plan, Kardex, physician orders, Safe Patient Handling (SPH) evaluations, and nursing assistant (NA) assignments. These inconsistencies ranged from requiring a mechanical lift with two staff, to a stand and pivot transfer with a gait belt, to a one-person assist, with no evidence of consistent communication or documentation to ensure safe transfers. Staff interviews confirmed the lack of alignment and clarity in transfer instructions across different documentation sources. For another resident with type II diabetes and muscle weakness, similar inconsistencies were found. The care plan, Kardex, physician orders, SPH evaluation, and NA assignments all contained differing information regarding the resident's transfer and ambulation needs, ranging from supervision with a walker to requiring a mechanical lift with two staff. Staff interviews acknowledged that the SPH status was not consistently reflected across all forms of communication and documentation, and that the information should be uniform to ensure safe care. These findings were based on record reviews, staff interviews, and a community complaint alleging frequent patient falls and safety risks.