Failure to Develop and Implement Comprehensive Care Plan for Resident Requiring Hydraulic Lift
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to address a resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan did not include any focus, goal, or intervention related to the resident's requirement for a hydraulic lift and transfer device, despite the resident being bedbound and dependent on staff for all transfers. The resident's diagnoses included cerebrovascular disease, right-sided hemiplegia, peripheral vascular disease, dementia, major depressive disorder, and bipolar disorder, and he was severely cognitively impaired and required a wheelchair for mobility. On one occasion, a CNA obtained the resident's weight using a hydraulic lift and transfer device without the required assistance of a second staff member. The CNA stated she proceeded alone because her assigned coworker was late and nurses were busy, acknowledging that this was not the correct procedure and that she had been trained to always use two staff members for such transfers. Facility policy and the CNA's skills validation checklist both required two staff members for all hydraulic lift operations to ensure safety. Interviews with the ADON and DON confirmed that the resident had long required a hydraulic lift for all transfers and that two staff members were always required for its use. Both acknowledged that the resident's care plan should have included specific instructions regarding hydraulic lift and transfer care, and that it was the DON's responsibility to ensure all resident care needs were accurately reflected in the care plan. The failure to include these details in the care plan and to follow established procedures led to the deficiency.