F0657

D

Failure to Maintain Accurate Care Plan for Bed Mobility Assistance

Hickory, North Carolina Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The facility failed to update and revise an individualized, person-centered comprehensive care plan to accurately reflect a resident's bed mobility needs. The resident, who had non-traumatic brain dysfunction, Alzheimer's disease, non-Alzheimer's dementia, seizure disorder, and severe cognitive impairment, was assessed as requiring substantial/maximal assistance with rolling in bed on a quarterly MDS. A Physical Therapy discharge summary recommended two-person assistance for transfers and gait, and a therapy note documented that the resident required partial/moderate assistance for rolling in bed. In an interview, the Physical Therapist stated the resident required moderate to maximum assistance of two staff members with everything and that, at discharge from therapy, the resident still required one-person assistance with bed mobility.

Despite these findings, the resident's care plan, updated on 01/16/26, documented that the resident was independent with bed mobility, requiring only verbal cues and occasional hands-on prompting, and the care guide likewise listed rolling left and right as independent. A NA reported that staff on the floor knew the care guide information was incorrect but had not reported it to anyone, even though they were expected to check and follow the care guide each morning. A nurse stated the resident required assistance of one staff member for bed mobility and that the MDS nurse was responsible for altering care plans and updating the care guide. The MDS nurse acknowledged responsibility for care plans, confirmed that therapy and NAs had indicated the resident needed at least one-person assistance for bed mobility, and stated the care plan should not have indicated independence and should have been correctly reflected in both the care plan and care guide.