Failure to Develop Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident, identified as Resident #83, who was on hospice services and had significant medical conditions including hemiplegia, hemiparesis, anxiety, major depressive disorder, and muscle wasting. The resident was observed in a fetal position with contractures in his lower extremities and left hand, yet there were no splints or positioning devices in place to assist with his condition. Despite the resident's cognitive skills being intact, the care plan did not address the management of his contractures or include interventions such as range of motion exercises or the use of splints and pillows. Interviews with facility staff, including the Director of Rehab, Registered Nurse Staff B, the Director of Nursing, and Care Plan Coordinators, revealed a lack of documentation and awareness regarding the resident's contractures and the absence of a restorative program. The staff confirmed that there was no care plan addressing the resident's lower leg contractures, and no documentation of therapy or interventions for the resident's condition. The facility's failure to document and implement a care plan for the resident's contractures was evident, as staff were unaware of the resident's needs and there was no evidence of education provided to direct care staff on how to manage the resident's condition.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. #83 care plan was updated to reflect resident current status. B. Education for F656 provided to RN staff B, care plan coordinator Staff L and Care plan coordinator RN staff H. C. Director of Rehab is no longer at the facility. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with contractors and limited ROM was conducted and any abnormal findings were corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on the components of F656. B. Nursing management will review 24 hour report and follow up on any new limited ROM or contractors and update care plan as needed. C. All New residents will be reviewed and reassessed if needed and review by the IDT team the following business day for any limited ROM or contractors to ensure appropriate interventions are in place. D. Education on F656 will be provided annually and upon new hire orientation. 4: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The Director of Care Plans /Designee will audit new residents chart and any change of condition charts to ensure that care plans are appropriate to reflect the status of the resident with emphasis on contractor or limited ROM weekly for four weeks then monthly for one quarter. The Director of Care Plans/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.