Failure to Update Care Plans with Resident-Specific Transfer Methods
Penalty
Summary
The facility failed to revise and update resident care plans to include resident-specific transfer methods, as required by facility policy and clinical documentation. For four residents reviewed for transfers, the care plans did not reflect the current transfer needs and methods, such as the use of mechanical lifts or the required number of staff for safe transfers. This deficiency was identified through policy review, medical record review, observations, and staff interviews. For example, one resident with a history of falls and total dependence for transfers was documented in therapy notes and on the Can-Do Information Sheet as requiring a Hoyer lift with two-person assistance. However, the care plan did not specify the use of a Hoyer lift for transfers. Another resident, who required a sit-to-stand mechanical lift and two-person assistance according to the Can-Do Information Sheet, also had a care plan that lacked this specific intervention. In both cases, staff interviews confirmed that the actual transfer methods used were not reflected in the care plans. Additional residents with significant mobility limitations, including those with severe cognitive impairment or a history of stroke, were also found to have care plans that did not match the documented transfer methods or staff assistance levels indicated in therapy assessments and Can-Do Information Sheets. The Director of Nursing confirmed that the care plans for these residents had not been revised to include the appropriate transfer methods, resulting in inconsistencies between the care plans and the actual care provided.