Failure to Care Plan and Order Specific Mechanical Lift Transfer Modes
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans that included specific, measurable objectives and timeframes for residents’ transfer needs, particularly the use of mechanical lifts. For multiple residents with diagnoses such as muscle weakness, unsteadiness of feet, lack of coordination, repeated falls, multiple sclerosis, contractures, and muscle wasting, the comprehensive MDS assessments did not indicate the use of mechanical lifts. Despite these conditions and histories of falls, the residents’ care plans either generically referenced adaptive equipment or assistance with transfers without specifying the type of transfer aid or mechanical lift to be used. For one resident with moderate cognitive impairment and a history of falls, the care plan identified fall risk and referenced adaptive equipment but did not specify the transfer aid, and there was no physician order for a sit-to-stand device, even though the resident reported that some staff transferred her using a machine. Another resident with severe cognitive impairment and lower extremity weakness had a care plan that stated he would be assisted with transfers and use adaptive equipment, but it did not identify the specific transfer aid, and there was no physician order for a sit-to-stand, despite the resident stating he began using a sit-to-stand device when his legs became weaker. Surveyor observation confirmed CNAs using a sit-to-stand machine to transfer this resident to a wheelchair. Additional residents with severe or moderate cognitive impairment, repeated falls, muscle weakness, lack of coordination, multiple sclerosis, contractures, and muscle wasting were not care planned for the specific use of Hoyer lifts or other mechanical lifts, and their physician orders did not include these devices. Their care plans referenced varying levels of staff assistance for ADLs and the use of adaptive equipment but did not identify the specific transfer mode or mechanical lift in use. Facility policy required comprehensive person-centered care plans with measurable objectives and timeframes to meet residents’ needs as identified in the comprehensive assessment, but the care plans for these residents did not reflect the specific transfer needs or mechanical lift use that was being provided.
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