F0656

D

Failure to Implement Updated Transfer Care Plan and Sit-to-Stand Training

Sequim, Washington Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly update and consistently implement care-planned transfer interventions for a resident admitted with moderate cognitive impairment, dependence in ADLs, and medically complex conditions. The admission MDS showed no prior use of a mechanical lift and no refusals of care. The resident’s care plan, initiated shortly after admission, included a goal to improve functional status, including transfers, and initially specified a two-person dependent assist using a Hoyer lift, later revised to a sit-to-stand lift. A Social Services care conference note documented that the resident had progressed from the Hoyer to the sit-to-stand lift, and a PT discharge note stated the resident had reached maximum potential, completed sit-to-stand training, and required two staff and a sit-to-stand lift for transfers.

Despite these documented therapy recommendations and care plan revisions, multiple interviews and records indicated that staff continued to use the Hoyer lift rather than the sit-to-stand lift. The resident’s caregiver reported observing staff using the Hoyer lift several times in December and never seeing the sit-to-stand used, including on the day of discharge, and stated the resident had no idea how to use the sit-to-stand at home. A case manager also reported observing staff using the Hoyer lift on multiple visits, including a specific instance when staff transferred the resident out of bed with a Hoyer for an appointment, despite the expectation that the sit-to-stand be used in preparation for discharge home. Social Services staff acknowledged the concern, stated that therapy had cleared the resident for the sit-to-stand, and said staff were instructed to use the sit-to-stand, but believed staff may have continued using the Hoyer because it was easier.

Nursing and therapy staff interviews and documentation further demonstrated inconsistency between the care plan and actual practice. The PT stated that at therapy discharge the recommendation was for sit-to-stand transfers and that they were unaware staff were still using a Hoyer or that the resident was refusing to get up; they would have expected a new PT referral if a decline or change in lift use occurred. Nursing assistants and an LPN recalled the resident as a Hoyer lift user and did not recall specific instructions to use the sit-to-stand prior to discharge. The DON and Resident Care Manager both described the resident as often not wanting to get out of bed and being transferred with a Hoyer when he allowed transfers, and the DON believed days without transfers reflected refusals. However, review of the task record for nearly a month before discharge showed the resident was transferred only 16 times, with only six entries indicating sit-to-stand mobility, and progress notes documented only one refusal (a declined shower), while the discharge MDS indicated the resident did not display rejection of care. This combination of documentation and interviews showed the facility did not consistently implement the updated care plan interventions to maintain the resident’s functional ability in preparation for discharge home.