Failure to Follow Care-Plan Transfer Method Using Mechanical Lift
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred according to her care plan and care sheet, specifically regarding the use of a stand aid lift. After a fall on 1/11/26, the resident, who had previously transferred with one-person assist and used a walker, began experiencing significant leg pain and was evaluated in the emergency room. Following this event, physical therapy re-evaluated her on 1/13/26 and recommended use of a stand aid lift for safe transfers, and this transfer status was reflected on her care sheet, which staff were expected to follow. Despite these updated transfer instructions, on 1/14/26 a CNA transferred the resident from the commode to the bed using only a gait belt and a pivot transfer instead of the ordered stand aid lift. The CNA later admitted to not using the stand aid lift as indicated on the resident’s care sheet. After this transfer, the resident complained of increased pain in her left knee, and the CNA notified the nurse, who provided pain medication. The incident was subsequently reported by physical therapy staff to the administrator and DON after the resident described the transfer and associated pain. Interviews and record review showed that staff were expected to provide care based on information in the resident’s care sheet, which included transfer status and other care needs, and that these care sheets were updated daily by management. Staff, including CNAs and nursing staff, confirmed that changes in a resident’s condition were to be communicated so that care sheets could be updated, and that new admissions were verbally reviewed and then formally assessed by PT for safe transfer recommendations. The facility was unable to provide a written policy for following residents’ care plans, using mechanical lifts, or transferring residents, even though the CNA job description required care consistent with the plan of care and facility policies and processes.
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