Failure to Develop Care Plan for Foot Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address the contractures of the feet for a resident with a history of cerebral infarction and severe joint immobility in both ankles. Observations showed the resident lying in bed with both ankles extended downward and no adaptive devices in use. Interviews with staff confirmed that the resident had longstanding foot drop and only heel pads were used to prevent skin breakdown, with no specific interventions or care plan in place for the contractures. Record reviews further indicated that the resident had significant lower extremity impairment and severe joint immobility, but there was no documented evidence of a care plan addressing these issues. Staff interviews, including with a CNA, LVN, and the DON, confirmed the absence of a care plan for the resident's contractures, despite facility policies requiring comprehensive, person-centered care plans to address such needs. The lack of a care plan meant that the resident did not receive tailored interventions to manage or prevent worsening of the contractures, as required by the facility's own policies and procedures regarding care planning and mobility management.