Failure to Develop Timely Baseline Care Plan for Safe Transfers
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with paraplegia and multiple fractures, as required by policy and professional standards. Upon review, it was found that there was no care plan addressing the resident's transfer needs until several days after admission, despite the resident being dependent and requiring a mechanical lift for transfers. The absence of this information in the baseline care plan meant that staff did not have written instructions on how to safely transfer the resident during the initial period after admission. Interviews with facility staff, including the MDS Coordinator, DON, DOR, and other nursing staff, revealed that there was confusion and lack of clarity regarding responsibility for creating and updating the baseline care plan. Although therapy staff evaluated the resident and determined the need for maximum assistance with a mechanical lift, this information was not promptly incorporated into the care plan. Staff relied on verbal communication rather than documented instructions, and several staff members were unsure who was directly responsible for ensuring the care plan was completed and updated. The facility's own policy required that a baseline care plan be developed within 48 hours of admission, addressing initial goals and services, including transfer needs. However, the care plan for this resident did not include transfer instructions until well after the required timeframe. This deficiency was identified through record reviews and staff interviews, which confirmed that the lack of a timely and complete baseline care plan could result in staff not knowing how to safely transfer the resident.