Failure to Update Care Plan After Safety Concern with Mechanical Lift Use
Penalty
Summary
The facility failed to develop a resident-centered care plan after identifying a safety concern involving a resident who required substantial to maximal assistance for transfers and activities of daily living due to muscle wasting, abnormal posture, and moderately impaired cognitive skills. The resident's responsible party was observed using a Hoyer lift to transfer the resident from bed to chair without staff assistance, despite the resident's lack of capacity to understand and make decisions. The care plan in place addressed general fall risk and included interventions such as frequent safety reminders and education for the resident, family, and caregivers, but did not specifically address the issue of unauthorized use of the Hoyer lift by the responsible party or the storage of the lift in the resident's room. Interdisciplinary team meeting notes documented that staff had discussed the safety concern with the resident's family after observing the unauthorized transfer. However, the care plan was not updated to reflect this specific risk or to provide clear instructions regarding the use and storage of the Hoyer lift. The Director of Nursing confirmed that a care plan for non-compliance or lack of knowledge was not initiated, and the facility's policy required comprehensive, individualized care planning based on assessed needs and changes in condition or behavior.