Failure to Update Care Plan for Resident's Mobility and Brace Use
Penalty
Summary
The facility failed to update and revise the care plan to reflect current interventions for a resident who had recently completed occupational therapy for left wrist weakness and joint pain. The resident was provided with a wrist brace and discharged from therapy with instructions to use the brace as tolerated and to walk independently with a walker. Despite these changes, the care plan continued to list a walking program requiring staff assistance and did not mention the use of the wrist brace. Interviews with therapy and nursing staff confirmed that the care plan was outdated and did not reflect the resident's current level of independence or the use of the brace. Additionally, the care plan lacked documentation regarding the monitoring of the wrist brace for potential skin integrity issues, as noted by a registered nurse who stated that all braces and splints should be care planned to ensure proper monitoring. The facility's policy required care plans to be updated as the resident's condition and care needs changed, but this was not done in this case. The deficiency was identified through observation, interviews, and document review, which showed a disconnect between the resident's current needs and the interventions documented in the care plan.