Failure to Develop and Implement Comprehensive Care Plan for Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically omitting individualized interventions for contractures in the resident's right hand and neck. The resident, a male with a history of intracranial injury, spastic hemiplegia, and contractures, was assessed to have functional limitations in range of motion in both upper and lower extremities. Despite these documented conditions, the care plan only included basic interventions for assistance with activities of daily living and did not address specific contracture management for the right hand or the neck. Multiple observations revealed that the resident was consistently without appropriate positioning devices or splints for his right hand and neck contractures while in his Geri-chair and bed. Staff interviews confirmed that the resident previously had a pillow for his neck and a splint or hand roll for his hand, but these were no longer in use. A CNA reported uncertainty about whether to use a rolled-up washcloth in the resident's hand due to the lack of an order, and the MDS Coordinator acknowledged that the care plan lacked individualized interventions for the contractures, particularly for the neck, which she had not considered a contracture. Therapy staff indicated that the resident had not received therapy since the previous year, and the occupational therapy discharge summary had recommended the use of a palmar guard for the right hand. The Director of Nursing stated that staff are expected to identify contractures and develop individualized care plans, but this had not occurred for the resident's neck contracture. The facility's care planning policy requires comprehensive plans that address all resident needs, but this was not followed in this case.