Failure to Develop and Implement Comprehensive Care Plan for Resident with Restraint and G-Tube Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with complex medical needs, specifically regarding the use of a wheelchair seatbelt restraint and the prevention of gastrostomy tube (g-tube) dislodgement. The resident, a female with Lennox-Gastaut Syndrome, seizure disorder, aphasia, and dependence on a wheelchair, was observed using a seatbelt restraint at all times while in her wheelchair. The care plan referenced the use of the seatbelt for fall prevention and seizure safety but did not include specific interventions to address risks associated with restraint use, such as monitoring, supervision, or parameters for release. There was also no physician's order specifying the use or monitoring of the restraint, and the consent documentation was incomplete regarding the type of restraint used. Staff interviews revealed that the seatbelt restraint was applied routinely without documented consideration of less restrictive alternatives or formal processes for monitoring and supervision. The DON confirmed that alternatives were not attempted and that the need for the restraint was not formally re-evaluated, despite facility policy requiring such documentation. The care plan did not address the restraint as a restraint, and staff were unaware of additional documentation or assessment requirements beyond routine application and observation. Additionally, the facility failed to revise the care plan following two hospitalizations for g-tube dislodgement. Although the resident began wearing an abdominal binder to prevent further dislodgement, this intervention was not reflected in the care plan or in the electronic medical record as a routine task for staff. Staff interviews confirmed that checks for the binder's placement were performed out of routine rather than as a documented intervention, and the nurse responsible for care plans had not updated the plan to address the risk of g-tube dislodgement.