Inaccurate Care Plan Documentation for Bed Mobility Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records for a resident with dementia and neuromuscular dysfunction who was admitted in April 2023. A community complaint reported to the state health department raised concerns about safety and care practices surrounding the resident’s fall on 1/12/2026. Nursing progress notes documented that the resident experienced a witnessed fall in his/her room while care was being provided, when one staff member was assisting with turning in bed and the resident fell out of bed onto the floor. A Quarterly MDS assessment indicated the resident was dependent for rolling in bed from back to side and returning to back. Review of the resident’s ADL care plan, initiated 4/14/2023 for physical limitations related to impaired mobility, showed conflicting interventions for bed mobility. One intervention, dated 6/7/2024, stated the resident required the assist of two staff and a sheet for turning and repositioning, while a later intervention, dated 12/23/2025, stated the resident required the assist of one staff and a sheet for turning and repositioning. The care plan did not clearly indicate which level of assistance was current, resulting in an incomplete and inaccurate description of the resident’s needs for turning and repositioning in bed. During an interview, the Regional Clinical Director, with the DON present, acknowledged that the earlier two-person assist intervention should have been removed when the one-person assist intervention was implemented and could not provide evidence that the care plan accurately reflected the resident’s needs.
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