Failure to Develop Care Plan for Splint Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident R27, who required a left resting hand splint. The deficiency was identified during a review of the facility's policy and clinical records, as well as through staff interviews. Resident R27 was admitted with diagnoses including flaccid hemiplegia affecting the left non-dominant side, diabetes, and hypertension. A physician's order dated December 26, 2024, specified the use of a left resting hand splint during waking hours, with instructions for frequent skin checks for irritation or breakdown and removal for hygiene purposes. Despite these orders, there was no evidence of a care plan addressing the use of the left resting hand splint in Resident R27's records. During an interview, the Director of Nursing confirmed the absence of a care plan for the splint and acknowledged that one should have been developed. This oversight indicates a failure to comply with the requirement to create a comprehensive, person-centered care plan that includes all necessary services to meet the resident's needs.
Plan Of Correction
R27 no longer needed the left-hand splint; therefore, the order has been discontinued. R27's care plan has been reviewed, and it has been determined to be personalized and appropriate. The Administrator will educate the Director of Nursing and Assistant Director of Nursing on the importance of the development and periodic review/revision of comprehensive person-centered care plans for each resident. The DON and/or the Assistant Director of Nursing will audit care plans of all residents with splints to ensure there's a comprehensive, personalized care plan that includes splint care. The DON and/or Assistant Director of Nursing will audit care plans for 5 random residents 3 times a week for 4 weeks to ensure that each one has a comprehensive, personalized care plan in place which appropriately reflects their specific needs. The results of the audits will be reviewed at the monthly Quality Assurance and Performance Improvement meeting.