Failure to Implement Accurate and Consistent Care Plan for Resident Transfers
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to meet a resident's medical and nursing needs. The care plan for a resident with cerebral palsy, repeated falls, impaired cognition, and other significant health issues did not consistently reflect the required level of assistance for transfers. Documentation discrepancies existed between the care plan and the kardex, with conflicting information about whether the resident required a one-person or two-person assist for transfers. This inconsistency led to confusion among staff regarding the appropriate transfer method. On the day of the incident, a CNA attempted to transfer the resident from a shower chair to a wheelchair alone, despite the care plan indicating a two-person assist was required. Another CNA observed the transfer, noted the resident was sliding down, and assisted in lowering the resident to the floor before notifying the charge nurse. Interviews with staff revealed that information about transfer assistance was available in the electronic health record and kardex, but there was uncertainty and lack of clarity due to the conflicting care plans. Some staff relied on word of mouth or their own judgment rather than consistently referencing the care plan. Further interviews and record reviews confirmed that the care plan had not been properly updated or resolved, resulting in staff not having accurate or consistent guidance on the resident's transfer needs. The MDS nurse acknowledged the error in documentation and the negative impact of an incorrect care plan, while the DON and administrator confirmed that staff were expected to follow the care plan and that discrepancies could lead to inadequate care. The facility's policies required comprehensive care planning and safe transfer procedures, but these were not effectively implemented in this case.