Failure to Update Care Plan After Discontinuation of Restraint
Penalty
Summary
The facility failed to update and revise a resident's care plan after the discontinuation of a restraint freedom splint. The resident, who had diagnoses including acute and chronic respiratory failure, encephalopathy, and quadriplegia, was totally dependent on staff for all activities of daily living and had severely impaired cognitive skills. The care plan, last revised on 3/26/2025, continued to indicate the use of a restraint freedom splint and identified the resident as high risk for injury and complications due to pulling life-sustaining equipment. A physician order dated 4/17/2025 directed the discontinuation of the freedom splint to the resident's left upper extremity. However, the care plan was not updated to reflect this change. Both the Subacute Director and the DON confirmed during interviews that the care plan should have been revised following the change in the resident's condition, but this was not done. The facility's policy also requires care plans to be revised as residents' conditions change, but this was not followed in this instance.