Failure to Coordinate Prosthetic Care for Resident
Summary
The facility failed to provide adequate assistance and coordination of services for a resident, identified as R37, who required a prosthesis. R37, who was cognitively intact and had a history of a nontraumatic above-the-knee amputation due to diabetes, was motivated to increase independence through ambulation. Despite this, the facility did not ensure timely referral and treatment for a well-fitting prosthetic leg. R37's care plan indicated the need for a prosthetic during transfers, yet observations and interviews revealed that R37 was not wearing the prosthetic and had not received necessary adjustments or evaluations for its fit. The prosthetic was described as extremely uncomfortable, and no arrangements had been made by the facility for re-evaluation by the vendor. Interviews with staff, including LPN-B, NA-G, RN-C, and the physical therapist, indicated a lack of awareness and communication regarding R37's prosthetic needs. R37 had been discharged from physical therapy before receiving a new prosthetic, and there was no evidence of follow-up to ensure the prosthetic was usable. The certified occupational therapy assistant was unaware of R37's receipt of a new prosthetic and had not received any communication from nursing staff about R37's needs. The director of nursing was also unsure about the current status of R37's prosthetic and indicated that staff would assist with its use if it did not fit. The facility did not provide a policy on coordination of prosthetic care, and the administrator mentioned that staff worked with therapy on prosthetic care coordination, but no specific actions were documented.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Proper Prosthetic Care and Skin Monitoring: A resident with a right BKA, DM2, and Alzheimer's had a prosthesis applied improperly when the inner gel liner was omitted, and therapy noted blisters and redness on the residual limb and surrounding areas. The care plan and physician orders lacked individualized prosthetic wear, hygiene, and skin-monitoring interventions, and the facility did not document comprehensive wound assessments or evidence of a prosthetic care process.
A resident with a leg amputation did not receive appropriate care and assistance to use their prosthesis, as staff did not routinely apply the device or include its management in the care plan or provider orders. The prosthesis was often left unused, and staff only applied a shrinker daily, despite the resident's desire to improve mobility. Documentation and staff interviews confirmed the absence of instructions or support for prosthesis use outside of therapy sessions.
A resident with bilateral lower extremity amputations experienced a delay in receiving a left leg prosthetic due to missing documentation, despite measurements being completed. The resident was not included in the restorative therapy caseload, and the facility's records lacked a care plan for the amputation. This delay hindered the resident's ability to ambulate, contrary to the facility's Prosthesis Care and Management policy.
A resident with a below-the-knee amputation experienced prolonged issues with a poorly fitting prosthesis, which the facility failed to address in a timely manner. Despite receiving a prosthesis, the resident reported discomfort and pain, leading to an inability to use it effectively. The facility did not follow up on the prosthesis issues for several months, and the resident's insurance was not billed for the original prosthesis. The Director of Rehabilitation later discovered these issues and initiated steps to resolve them.
A resident with a prosthetic leg was admitted to a facility with a bed bug infestation. The facility failed to treat the prosthetic for bed bugs due to unpaid extermination services, leaving the resident without the prosthetic and impacting therapy sessions. Staff attempts to clean the prosthetic were unsuccessful, and the resident expressed agitation over the missing prosthetic.
A resident with a left below-knee amputation was unable to use his prosthesis due to a missing liner, hindering his gait training. Despite notifying the DOR, the facility delayed ordering a replacement until after the resident called 911. The prosthetic company required a prescription, and further delays occurred due to payment issues, resulting in the liner being delivered only after payment was made.
Failure to Provide Proper Prosthetic Care and Skin Monitoring
Penalty
Summary
The facility failed to ensure a resident with a right below-the-knee prosthesis received appropriate care and assistance to maintain physical well-being. The resident had diagnoses including right below-the-knee amputation, Type 2 diabetes with a left foot ulcer, and Alzheimer's disease, and was moderately cognitively impaired with a BIMS score of 12. The facility policy required routine assessment of the prosthetic device and the resident's skin integrity, assistance with application and removal as needed, and documentation of assessments and abnormalities, but the resident's care plan and physician orders did not include individualized interventions for safe prosthetic use, wear schedule, hygiene, or skin monitoring. On April 14, 2026, after returning from therapy, the resident removed the prosthetic device and blisters were observed on the right residual limb. The nurse practitioner and wound nurse were notified and orders were received for skin prep and an ABD dressing daily. A physical therapy note from the same day documented that the resident arrived to therapy with the prosthetic leg donned, but it had not been applied properly and the inner gel liner had not been placed before the prosthesis. The therapist observed blisters to the right lateral knee and anterior medial thigh, along with redness to the patella. Facility documentation later described treatable wounds of the left heel and right prosthesis site, but no specific wound location on the residual limb, measurements, characteristics, staging, or detailed assessment findings were documented. There were also no documented wound assessments addressing the blisters and redness noted by therapy, including location, description, drainage, or treatment effectiveness. During interview, the NHA, DON, and Director of Therapy were unable to provide documented evidence of a prosthetic care assessment process, wearing schedule, residual limb skin monitoring protocol, staff education, resident education, or comprehensive wound assessments related to the resident's prosthetic use.
Failure to Provide Care and Assistance for Resident with Prosthesis
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a leg prosthesis, as required by facility policy and the resident's care needs. The resident, who was cognitively intact and dependent on staff for activities of daily living, had received a prosthetic leg and expressed a desire to use it to improve mobility and facilitate discharge. Despite this, observations showed the prosthesis was not in use, often left on the windowsill, and staff interviews confirmed that the prosthesis was not routinely applied. Instead, staff only applied a shrinker in the morning and removed it at night, with no regular support for prosthesis use. Record review revealed that the resident's care plan did not address the presence or use of the prosthesis, nor did it include instructions for wear time, fit, care, or the use of associated components like the limb sock and shrinker. Provider orders and progress notes also lacked any mention of the prosthesis or its management, despite documentation from the prosthesis clinic indicating the resident had received education on its use and care. The clinic also instructed the facility to report any issues with fit, pain, or skin integrity, but there was no evidence these instructions were incorporated into the resident's care plan or daily care routines. Interviews with therapy and nursing staff indicated that the resident only wore the prosthesis during therapy sessions and not as part of daily care, with therapy discontinued after a period of time. Staff cited the resident's reluctance to be out of bed and discomfort as reasons for limited use, but there was no documentation of care refusals or efforts to encourage or assist with prosthesis use outside of therapy. The lack of a comprehensive care plan and absence of provider orders addressing the prosthesis contributed to the resident not receiving the necessary support to use the device, contrary to facility policy and best practices for prosthesis management.
Failure to Provide Timely Prosthetic Care
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthetic device, specifically in preparing the left prosthetic device for use. The resident, who was readmitted following an amputation of the left lower extremity, had a history of Type 2 Diabetes Mellitus, bilateral lower extremity amputations, muscle weakness, and limited activity due to disability. Despite the resident's eagerness to receive the left leg prosthetic and the completion of measurements, there was a significant delay in obtaining the prosthetic device, which was attributed to the need for additional documentation from the provider. The clinical records did not reflect a care plan for the left lower extremity amputation or an order for prosthetic follow-up. The resident expressed frustration and concern over the delay, fearing muscle weakness due to the prolonged wait. Interviews with staff revealed that the resident was not on the restorative therapy caseload, despite the existence of a special treatment plan for residents with prosthetic needs. The delay was further compounded by the lack of a signed and dated letter of medical necessity, which was only drafted on March 6, 2025. The facility's Prosthesis Care and Management policy mandates that residents with prosthetic devices receive the necessary care and assistance to use their prostheses. However, the resident's inability to ambulate due to the delay in receiving the prosthetic device highlights a failure to meet this policy. The resident attended prosthetic fitting appointments, but the lack of a timely follow-up and the absence of a comprehensive care plan contributed to the deficiency identified by the surveyors.
Failure to Address Prosthetic Limb Issues Timely
Penalty
Summary
The facility failed to address a resident's issues with a prosthetic limb in a timely manner, affecting one of two residents with prostheses. The resident, who had a below-the-knee amputation, was admitted with multiple diagnoses including severe protein calorie malnutrition, type two diabetes mellitus, and opioid dependence. The resident received a prosthesis on April 25, 2024, but experienced discomfort and fitting issues, which were not promptly resolved. The resident's physical therapy notes indicated ongoing problems with the prosthesis, including discomfort and pain, leading to the resident's inability to tolerate wearing it. Despite being instructed to contact the prosthetic company for adjustments, the resident continued to experience issues. The resident was discharged from physical therapy on May 30, 2024, due to meeting the highest practical level of achievement, yet still could not use the prosthesis effectively. Occupational therapy also noted non-compliance with the treatment plan, further complicating the situation. The Director of Rehabilitation, who started in September 2024, discovered that the resident's insurance had not been billed for the original prosthesis, and the prosthesis was returned due to its poor fit. The resident had a lump on the limb that was not accommodated by the prosthesis, and the straps caused skin irritation. The facility's failure to follow up on the prosthesis from May 30, 2024, to September 10, 2024, contributed to the deficiency, as the resident remained without a properly fitting prosthesis for an extended period.
Failure to Provide Prosthetic Due to Untreated Bed Bug Infestation
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a prosthesis by not timely treating the prosthetic device for bed bugs. The resident, who had a traumatic leg amputation and other medical conditions, was admitted with a prosthetic leg infested with bed bugs. Upon admission, the resident's belongings, including the prosthetic, were bagged and placed in a contained area outside the facility due to the infestation. However, the facility did not contact an exterminator to treat the items because of an unpaid balance with the extermination service provider. The resident's medical records and therapy notes indicated that the absence of the prosthetic leg was a barrier to the resident's therapy sessions and independence. Despite the resident's need for the prosthetic to improve mobility and independence, the facility did not ensure the prosthetic was decontaminated and returned to the resident. The resident expressed agitation over the missing prosthetic, and therapy sessions were impacted due to its unavailability. Interviews with facility staff revealed that attempts to clean the prosthetic with insecticide were unsuccessful, and the facility's environmental manager confirmed that no extermination efforts had been made. The facility's administrator acknowledged the unpaid extermination services and the lack of extermination since August 2024. The facility's failure to address the bed bug infestation and provide the resident with a usable prosthetic leg resulted in a deficiency during the complaint investigation.
Failure to Replace Lost Prosthetic Liner
Penalty
Summary
The facility failed to facilitate the replacement of a lost prosthetic liner for a resident with a left below-knee amputation, which hindered the resident's ability to use his prosthesis and walk. The resident, who was cognitively intact but had moderate vision impairment, was unable to continue gait training due to the missing liner. Physical therapy documentation indicated that the resident was unable to perform static standing or ambulate for several days because the gel sleeve for the prosthesis could not be located. Despite notifying the Director of Rehab (DOR) and requesting a replacement, the issue persisted, and the resident was discharged from therapy without meeting his ambulation goals. The resident reported the missing prosthetic liner to 911, prompting a facility service concern report. The report noted that the resident claimed the liner had been missing for 30 days, and the DOR contacted a prosthetic company to check the availability of a replacement. However, the facility did not place the order until after the resident's 911 call, and the prosthetic company required a prescription to proceed. The prescription was sent, but the liner was not in stock, causing further delays. The prosthetic company notified the facility when the liner arrived, but payment was not made until a month later, delaying delivery. Interviews with staff revealed that the DOR was aware of the missing liner after the resident's 911 call, but the Director of Nursing (DON) was not informed until the clinical meeting following the incident. The prosthetic company confirmed that the facility's first request for the liner was made the day after the 911 call, and the liner was delivered only after payment was received. The resident expressed frustration over the lack of assistance in obtaining a new liner, which prevented him from using his prosthesis and continuing therapy.
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