Failure to Follow Care Plan Transfer Requirements Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan for a resident whose assessment and care plan required use of a mechanical total lift with a green sling and assistance of two staff for all transfers. The resident was admitted with diagnoses including unspecified dementia, scoliosis, and overactive bladder, and had a BIMS score indicating moderate cognitive impairment. The comprehensive care plan, initiated shortly after admission and later updated, identified a self-care deficit and risk for decline related to impaired mobility, with interventions specifying assistance with ADLs, two-person assist, and use of appropriate equipment. On 02/25/2025, the care plan and device assessment were updated to require a total lift with green sling and two-person assist for transfers, including transfers to the tub, and this requirement was also reflected on the resident’s assignment sheet. Despite these documented requirements, on 04/09/2025 a CNA transferred the resident from wheelchair to bed without using the mechanical lift and without a second staff member. During this transfer, the resident sustained a full-thickness vertical laceration to the right lower leg that extended to the bone, reportedly caused by contact with the iron bed frame. The injury required control of bleeding at the facility and subsequent evaluation and treatment at a local hospital, where the diagnosis of leg laceration was confirmed and sutures were placed. Hospital discharge instructions included daily warm soapy washes, antibiotic ointment, elevation to prevent swelling, optional light compression, and suture removal after 10 days. Interviews and record reviews confirmed that the requirement for a total lift with green sling and two-person assist was clearly communicated and available to staff. The assignment sheet listed the need for a lift with two-person assist and the specific sling color, and other CNAs stated that such information is routinely provided on assignment sheets and can also be verified in the electronic care plan or care guide. The MDS nurse stated that care plans are developed to ensure staff follow standards of care based on resident needs, and the DON and nursing staff confirmed that it was their expectation that staff follow care plan interventions. The DON and Interim Executive Director indicated that the CNA who performed the transfer was aware of the lift and two-person assist requirement but chose to transfer the resident independently without the mechanical lift, leading to the resident’s injury.
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