Failure to Develop and Implement Comprehensive Care Plan for Resident with Hemiplegia
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex diagnoses, including cerebral infarction, hemiplegia, contracture of the right lower leg, muscle weakness, vascular dementia, and joint pain in the right hand. Observation revealed the resident's right hand was slightly contracted, and the resident reported wearing a right-hand splint at night, which she felt was beneficial. Physician orders specified the use of a right resting hand splint during the night shift, and the MAR confirmed its application and removal times. However, prior to May 22, 2025, the resident's care plan did not address right-sided hemiplegia, the use of the right-hand splint, or pain management. The DON confirmed that a care plan for these issues should have been in place.