Failure to Follow Care Plan Requiring Two-Person Assist With EZ Stand Transfer
Penalty
Summary
Surveyors identified a deficiency in the implementation of a comprehensive person-centered care plan when staff did not follow the documented transfer assistance requirements for a resident. The resident had been admitted with diagnoses including type 2 diabetes mellitus, muscle wasting and atrophy, and dementia, and an MDS assessment showed the resident was severely impaired in cognitive skills and required substantial/maximal assistance for bathing, dressing, toileting hygiene, oral hygiene, and personal hygiene. The resident’s care plan, developed and later revised due to high fall risk related to confusion and balance problems, specified the intervention to use a 2-person assist for all transfers with an EZ stand. Despite this care plan intervention, a CNA reported, and the resident’s responsible party confirmed, that on a specified evening the CNA used the EZ stand alone to transfer the resident to the bathroom, without a second staff member assisting. The DON acknowledged that the purpose of the care plan was to communicate interventions staff should use to address resident needs and that interventions related to fall risk should be followed by staff. The facility’s policy on comprehensive person-centered care plans stated that a care plan with measurable objectives and timetables must be developed and implemented for each resident, but in this instance the intervention requiring two staff for EZ stand transfers was not implemented as written.
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