Failure to Provide Care and Assistance for Resident with Prosthesis
Penalty
Summary
The facility failed to provide appropriate care and assistance for a resident with a leg prosthesis, as required by facility policy and the resident's care needs. The resident, who was cognitively intact and dependent on staff for activities of daily living, had received a prosthetic leg and expressed a desire to use it to improve mobility and facilitate discharge. Despite this, observations showed the prosthesis was not in use, often left on the windowsill, and staff interviews confirmed that the prosthesis was not routinely applied. Instead, staff only applied a shrinker in the morning and removed it at night, with no regular support for prosthesis use. Record review revealed that the resident's care plan did not address the presence or use of the prosthesis, nor did it include instructions for wear time, fit, care, or the use of associated components like the limb sock and shrinker. Provider orders and progress notes also lacked any mention of the prosthesis or its management, despite documentation from the prosthesis clinic indicating the resident had received education on its use and care. The clinic also instructed the facility to report any issues with fit, pain, or skin integrity, but there was no evidence these instructions were incorporated into the resident's care plan or daily care routines. Interviews with therapy and nursing staff indicated that the resident only wore the prosthesis during therapy sessions and not as part of daily care, with therapy discontinued after a period of time. Staff cited the resident's reluctance to be out of bed and discomfort as reasons for limited use, but there was no documentation of care refusals or efforts to encourage or assist with prosthesis use outside of therapy. The lack of a comprehensive care plan and absence of provider orders addressing the prosthesis contributed to the resident not receiving the necessary support to use the device, contrary to facility policy and best practices for prosthesis management.