Failure to Implement and Develop Comprehensive Care Plans for Orthotic Devices and Fall Prevention
Penalty
Summary
The facility failed to implement and develop comprehensive, person-centered care plans for several residents requiring orthotic devices and for a resident needing a specific fall prevention intervention. For four residents with orders for splints or braces, the care plans either lacked necessary interventions, such as range of motion (ROM) exercises, or the interventions listed were not carried out as specified. Observations revealed that splints and braces were not applied as ordered, and staff interviews confirmed inconsistent application and lack of awareness regarding care plan details. In some cases, splints were found unused in residents' rooms, and staff admitted to not performing required ROM prior to splint application. Additionally, the facility failed to ensure that interventions for fall prevention were implemented as documented in the care plan. One resident, who had experienced multiple falls, had a care plan intervention to apply brightly colored tape to the call light as a visual reminder to request assistance before ambulating. However, repeated observations showed that the call light did not have the required colored tape, and staff interviews confirmed that the intervention was not in place. There was also a lack of clarity among staff regarding responsibility for ensuring that such interventions were implemented and maintained. The facility's policies required that care plans be comprehensive, person-centered, and regularly updated by the interdisciplinary team, with staff notified of their responsibilities. However, interviews with staff, including CNAs, the MDS Coordinator, the DON, and the Administrator, revealed gaps in communication, training, and policy availability. Some staff were unaware of their roles in applying splints or following up on care plan interventions, and the facility lacked specific policies on restorative nursing services and splinting. These deficiencies resulted in residents not receiving care as planned and documented.