Failure to Implement Care Plan Interventions for Transfer and Supervision
Penalty
Summary
The facility failed to implement the care plan interventions for a resident who required specific transfer and supervision protocols. The resident's care plan indicated that all transfers from bed to chair or toilet were to be performed using a Sara Steady mechanical lift and that care was to be provided in pairs (two staff members present) due to previous behavioral concerns and accusations made by the resident. Despite these documented interventions, staff were observed transferring the resident without the required mechanical device and without a second staff member present. Additionally, there was confusion among staff regarding the specifics of the care plan, with some staff unaware of the need for paired care or the use of the Sara Steady lift. Interviews revealed that staff did not consistently read or follow the care plan, leading to inconsistent application of required interventions. One nursing assistant admitted to transferring the resident alone and without the mechanical lift, stating she had not reviewed the care plan prior to providing care. Other staff members, including nurses and therapy staff, expressed uncertainty about the requirements for paired care and whether these applied to their roles. Documentation and communication gaps were evident, as some staff relied solely on the treatment administration record (TAR) and did not routinely review the full care plan, resulting in missed interventions. The resident involved had a history of sepsis, alcohol-induced chronic pancreatitis, lymphedema, and osteoarthritis, and was dependent on staff for most activities of daily living. The care plan also noted behavioral concerns, including making accusations against staff of different ethnicities, which contributed to the requirement for care in pairs. Despite these needs, the facility did not ensure that all staff were aware of or adhered to the care plan interventions, leading to the observed deficiencies in care delivery.