Failure to Clearly Define and Update Resident Transfer Status and Method
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards by not clearly directing staff on a resident’s transfer method and not completing a timely assessment when the resident’s transfer ability changed. The resident had dementia, anxiety, and rheumatoid arthritis, with a BIMS score indicating moderate cognitive impairment, and required substantial/maximal assistance with toilet use and transfers, was dependent with wheelchair use, and was of small stature and low weight. The Resident Care Plan initially directed transfer with assistance of one staff to wheelchair, but was later updated to include two staff for transfers, resulting in conflicting directions that simultaneously called for one and two staff assistance. A physician’s order directed out-of-bed transfers with assistance of one staff using a gait belt, and the NA care card also directed transfer and mobility assistance of one staff. There was no documentation in the physician’s orders, care plan, or NA care card directing the use of a mechanical (Hoyer) lift. Despite the lack of documented orders or care plan direction for a mechanical lift, multiple staff interviews revealed that some nurses and NAs believed the resident required a Hoyer lift for transfers due to leg weakness. The regular NA reported providing one-person assist for transfers but felt it would be safer to use a mechanical lift, while two RNs stated the resident’s transfer status was via Hoyer lift and that NAs were expected to follow the care card for transfer status. The DON stated she was unaware staff were using a mechanical lift and indicated that a change in transfer status should have been supported by an RN assessment or therapy evaluation, with corresponding updates to physician/APRN orders, the care plan, and the NA care card. No facility policy specific to directing staff on transfer status or resident assessments was provided, although a general Hoyer lift procedure and a care plan policy existed, further underscoring that the resident’s actual transfer method in practice was not aligned with the documented plan of care and orders.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.