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:
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.
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.
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