Failure to Consistently Implement Resident Mobility Care Plan
Penalty
Summary
Staff failed to consistently implement the physical mobility care plan for a resident with significant mobility limitations and multiple diagnoses, including Parkinson's disease, schizophrenia, and dementia. The resident was non-ambulatory and care plans specified the use of a Hoyer lift for all transfers. However, documentation and staff interviews revealed that staff sometimes transferred the resident manually with two people lifting her under the arms, rather than using the Hoyer lift as required by the care plan. This deviation from the care plan was confirmed by multiple CNAs and a review of handwritten notes, which indicated that the Hoyer lift was not always used during transfers. The resident was found to have a bruise and an acute fracture of the left pinky toe, with the cause initially unknown. Medical records and staff interviews confirmed that the resident was dependent on staff for all transfers and that the care plan had been updated to reflect the need for mechanical lift assistance. Despite this, staff admitted to not always following the care plan, instead choosing manual transfers based on their judgment of the resident's condition at the time. The incident was reported to the Department of Public Health, and the facility's Director of Nursing confirmed the care plan requirements and the injury.