Failure to Follow Care Plan for Mechanical Lift Transfer
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with Alzheimer's Disease and hypertension, who was admitted for hospice respite care. The resident had physician orders and care plan interventions specifying the use of a mechanical lift with two staff for all transfers. These requirements were documented in the resident's care plan and Kardex, which staff are trained to review prior to providing care. On one occasion, two CNAs transferred the resident from bed to a high-back wheelchair without using the required mechanical lift. Neither CNA reviewed the resident's Kardex or consulted the charge nurse to confirm the transfer status before performing the transfer. The family member of the resident observed the transfer and confirmed that a mechanical lift was not used. Both CNAs later acknowledged that they did not check the Kardex prior to the transfer and proceeded with a manual transfer involving two staff members. Interviews with facility staff, including the DON, MDS Nurse, and Administrator, confirmed that the resident's transfer status was clearly documented and that staff had been trained to use the Kardex to determine transfer requirements. The MDS Nurse indicated that the transfer status was entered into the Kardex the day after admission. The failure to follow the care plan and physician orders for mechanical lift transfers was identified as a deficiency, as it did not meet the resident's assessed needs and placed the resident at risk.