Failure to Care Plan and Obtain Order for Mechanical Lift Transfers
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered, comprehensive care plan that included measurable objectives and timeframes for a resident’s identified needs, specifically related to transfers. The resident was an older female admitted with COPD, muscle weakness, unspecified pain, Type 2 DM with complications, and a history of cerebral infarction. Her admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and Section GG documented a score of 1 for chair/bed-to-chair transfer, meaning she was dependent and required the assistance of two or more helpers for transfers. Despite these documented needs, the resident’s care plan initiated on 10/25/2025 addressed risk for pressure injury related to decreased bed mobility/transfers, incontinence, poor nutrition, history of skin breakdown, fragile skin, Braden risk score, and sensory perception, but did not address ADLs or specify the means of transfer. The CNA Kardex, printed on 01/29/2026, indicated that the resident required a two-person assist for chair/bed-to-chair transfers, but this information was not reflected in the comprehensive care plan. Additionally, review of the physician orders showed there was no order for transfer via mechanical lift, even though the resident required this level of assistance. During interviews, the DON stated that if a resident required a mechanical lift transfer, there should be a physician order, and that staff would learn of this need through shift report and the CNA Kardex. The DON acknowledged there was a safety issue when a resident was not care planned for mechanical lift transfer and there was no corresponding order. The MDS nurse, who was responsible for completing care plans, stated that the resident’s mechanical lift transfer should have been care planned and that she must have overlooked it, despite the MDS documenting that the resident was dependent for transfers. The facility’s own comprehensive care plan policy required development of a person-centered care plan within 7 days of the comprehensive MDS, inclusion of all triggered CAAs, and measurable objectives and timeframes to meet identified needs, but these requirements were not met for this resident’s transfer needs.
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