Failure to Follow Care Plan for Safe Resident Transfers
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was followed regarding transfer guidelines for a resident with multiple complex medical conditions, including multiple sclerosis, epilepsy, osteoporosis, and multiple leg contractures. The resident was cognitively intact and required total staff assistance for all activities of daily living due to chronic weakness and inability to bear weight or stand. The care plan specifically directed staff to use a mechanical lift with two staff members for all transfers between surfaces, such as from bed to wheelchair. Despite these directives, two nursing assistants manually lifted the resident from bed to wheelchair without using the mechanical lift, as confirmed by both the resident and staff interviews. The incident was acknowledged by the Resident Care Manager and Director of Nursing, who confirmed that the care plan had been updated to require mechanical lift transfers due to the resident's fragility and history of pathological fractures. The failure to follow the established care plan placed the resident at risk for injury and unmet care needs.