Failure to Update and Implement Care Plan for Post-Surgical Resident Results in Injury
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all of a resident's physical needs, specifically neglecting to include goals or interventions related to the use of adaptive devices following joint replacement surgery. The resident, an elderly male with multiple complex diagnoses including recent hip surgery, dementia, and generalized muscle weakness, was admitted after a joint replacement and required specific precautions and assistive devices such as a hip abduction pillow and two-person assist for transfers. Despite clear hospital discharge instructions and therapy recommendations, the facility's care plan, physician orders, and electronic health records did not reflect the need for these adaptive devices or specify the required assistance for transfers. Interviews and record reviews revealed that staff were inconsistently informed about the resident's needs. Some CNAs were aware of the use of cushions and wedges, while others were not, and there was confusion about when and how to use these devices during transfers and care. The MDS Coordinator stated that care plans were not updated when residents returned from hospitalization unless there were medication changes, and the care plan for this resident was not revised to reflect the need for adaptive devices or changes in transfer assistance. The lack of clear, updated documentation and communication led to staff performing transfers without the required two-person assist or use of a gait belt, as evidenced by video footage showing a CNA transferring the resident alone and without proper equipment. As a result of these failures, the resident experienced a right hip dislocation following an inappropriate transfer. The facility's policies required safe transfer practices, use of gait belts, and immediate communication of patient needs, but these were not followed or reflected in the care plan. Staff interviews confirmed gaps in knowledge and inconsistent practices regarding the use of adaptive devices and transfer assistance, and the care plan was not updated to reflect the resident's changing needs after hospitalization and surgery.