Failure to Implement Care Plan Interventions for Safe Transfers and Positioning
Penalty
Summary
The facility failed to implement care plan interventions and standards of care for safety with transfers, positioning, and wheelchair equipment for a resident with significant musculoskeletal and cognitive impairments. The resident, a male with dementia, chronic pain syndrome, a left hip prosthesis, intracranial injury, and muscle weakness, had a history of left hip dislocations and was care planned to have a knee immobilizer in place at all times, use left posterior hip precautions, and receive limited assist with sit-to-stand transfers to a wheelchair. The care plan also specified that the resident should eat meals in the dining room due to fall risk and required cueing for eating. Observations revealed multiple failures to follow the care plan. The resident was found eating breakfast in bed without staff assistance, struggling to cut food, and not using the dining room as care planned. The resident's wheelchair did not have a proper leg rest to support his left leg, and the walker with wheelchair footrests was left at his bedside, contrary to care plan instructions. During a transfer, a CNA did not use a gait belt and was unaware of the updated care plan interventions, including the requirement for a sit-to-stand lift for transfers. The CNA also did not know the resident was supposed to eat in the dining room and had not read the care plan that day. Interviews with staff confirmed a lack of awareness and implementation of updated care plan interventions. The physical therapist was unaware that the resident did not have a proper leg rest for his wheelchair, and the unit manager could not explain why the resident was not in the dining room for meals or why the walker was left at the bedside. Documentation indicated that staff were supposed to be informed of care plan updates through a "stop and sign" process, but the CNA had not seen or signed it until prompted during the survey.