Failure to Care Plan Transfer Assistance and Biliary Drain Management
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable interventions for two residents. For the first resident, who had an above-the-knee left leg amputation and osteomyelitis of the right foot and ankle, the activities of daily living (ADL) care plan dated 1/5/2026 listed a goal to improve the current level of function in ADLs and an intervention to transfer the resident with staff participation, but did not specify that two-person assistance was required for transfers. The resident’s history and physical dated 1/8/2026 documented fluctuating capacity to understand and make decisions, and a Minimum Data Set (MDS) dated 2/25/2026 showed moderately impaired cognitive skills, need for varying levels of assistance with ADLs, and impairment of one lower extremity that interfered with daily function or placed the resident at risk of injury. Further record review for the first resident showed a physician progress note dated 3/11/2026 indicating a possible right 5th metatarsal head impaction fracture, with an expectation of healing in six months. A physical therapy (PT) evaluation and plan of treatment dated 3/13/2026 specified that the resident required maximum, two-person assistance with transfers. In interviews, a CNA stated the resident required maximum assistance for transfers from bed to wheelchair due to the left leg amputation and right foot fracture, and the Director of Physical Therapy confirmed the need for two-person assistance because of an unsteady gait, fluctuating mobility, and changing mental status. The DON acknowledged that the resident’s care plan should have indicated the need for two-person assistance during transfers. For the second resident, who was admitted with malignant neoplasms of the colon and axilla/upper limb lymph nodes, the history and physical dated 2/21/2026 documented intact decision-making capacity, and the MDS showed intact cognitive skills with varying levels of assistance required for ADLs. An order recap report dated 2/26/2026 documented an order to flush an abdominal biliary drain tube with 10 ml of sterile saline every day and evening shift. However, review of the electronic medical record revealed no care plan addressing the abdominal biliary drain tube. In interviews, the DON stated that care plans are developed to implement goals and interventions for residents’ health concerns and confirmed that the use of an abdominal biliary drain should have been included in the care plan with directions to monitor the drain, drainage amount, signs of infection, and changes in condition and pain. The facility’s policy on comprehensive person-centered care planning, dated 4/2025, required development of a comprehensive care plan with measurable objectives and timeframes to meet residents’ medical, nursing, mental, and psychosocial needs.
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