Failure to Update Care Plan After Change in Transfer Assistance Needs
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan to accurately reflect the current level of assistance required for transfers and ADLs, as required by facility policy and regulatory standards. The facility’s nursing assessment policy states that assessments must accurately reflect the patient’s status at the time of assessment, that focused assessments should be completed as triggered, that change-in-condition assessments should be conducted as needed, and that assessment data must be used to develop the care plan. Despite this, the resident’s care plan, initiated after a significant change in condition, continued to indicate a need for two-person assistance with transfers and ADLs even after the resident’s functional status had improved. The resident was admitted with multiple fractures, including a displaced fracture of the posterior wall of the right acetabulum, a displaced fracture of the upper end of the right humerus, a wedge compression fracture of the first lumbar vertebra, polyosteoarthritis, age-related osteoporosis, low back pain, repeated falls, and unspecified dementia without behavioral disturbances. A significant change MDS showed a BIMS score of 2, indicating severe cognitive impairment, and documented impaired lower extremities with no mobility device use, while a later quarterly MDS documented wheelchair use. The care plan dated 12/03/2025 identified mobility and fall risk problems following multiple fractures and specified two-person assistance for transfers, bed mobility, dressing, and toileting, along with fall prevention measures and therapy coordination. PT orders and documentation showed that the resident’s functional status changed over time. PT evaluation and plan of treatment dated 01/19/2026 documented that the resident required substantial to maximal assistance from two staff for transfers. PT progress notes dated 01/27/2026 documented improvement to moderate assistance from one staff member for transfers. However, the care plan was not revised to reflect this change and continued to list two-person assistance. Interviews with a CNA, an LPN, the Unit Manager, the Rehab Director, and MDS staff confirmed that current practice was one-person assistance, that PT documentation showed the change, and that the care plan still indicated two-person assistance. Staff also confirmed that nursing staff could update the care plan and that the change in functional status had not been communicated or incorporated into the care plan, resulting in an inaccurate care plan for this resident.
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