Failure to Timely Revise Care Plans After Therapy Changes in Transfer Status
Penalty
Summary
The deficiency involves the facility’s failure to revise residents’ comprehensive care plans in a timely manner after changes in transfer status were identified by therapy. For one resident with malignant neoplasm of the anal canal and recent gastrointestinal surgery, the admission MDS documented that the resident was cognitively intact, had no rejection of care behaviors, was independent with bed mobility, and required set up or clean-up assistance for transfers. The ADL care plan dated 1/11/26 documented a self-care performance deficit related to gastrointestinal surgery, with interventions stating the resident was able to transfer with one staff and a front-wheeled walker, requiring partial assistance for bed-to-chair and chair-to-bed transfers and sit-to-stand. However, a Rehab Communication form dated 1/13/26 indicated that the resident’s transfer status had changed to independent in the room with a four-wheeled walker. On the day of surveyor observation, the nursing assistant caring for this resident stated she believed the resident could be independent in the room but had not verified the care plan or Kardex at the beginning of her shift. Upon review, she confirmed that the care plan still showed the resident required assist of one for transfers, while a separate Rehab Communication form showed the resident had been changed to independent on 1/13/26. The DON confirmed that the resident’s care plan for transfers still indicated assist of one and acknowledged that the care plan had not been revised in a timely manner to reflect the physical therapy recommendation for independent transfers with a walker, stating she had not had time to update the care plan. A second resident with chronic kidney failure, heart failure, atrial fibrillation, and a right heel pressure ulcer had an admission MDS indicating dependence for rolling and transfers, risk for pressure ulcers/injuries, and the presence of a surgical wound. The ADL care plan dated 1/6/26 documented a self-care deficit related to a hip fracture, with a goal to improve transfer function and an intervention specifying substantial one-staff assist with a sit-to-stand mechanical lift for toilet transfers. A Rehab Communication form dated 1/26/26 changed this resident’s transfer status to assist of one with a gait belt and wheeled walker, discontinuing the sit-to-stand lift. During observation, a nursing assistant prepared to transfer the resident to the commode using a walker and gait belt and stated she relied on the Rehab Communication form rather than the care plan/Kardex to determine transfer status. She verified that the care plan still required use of the sit-to-stand lift. The DON confirmed that the resident’s transfer status had been changed by therapy on 1/26/26 but that the care plan still reflected the sit-to-stand lift because it had not yet been updated, despite facility policy requiring review and revision of the care plan upon status change.
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