Failure to Update Care Plan Quarterly for Resident Using Hand Mitten Restraint
Penalty
Summary
The facility failed to review and revise the care plan quarterly for a resident who used a hand mitten as a restraint to prevent the removal of invasive tubing. The resident, admitted with diagnoses including acute respiratory failure with hypoxia and epilepsy, was noted to have significant cognitive impairment and required daily use of a limb restraint. The Minimum Data Set confirmed the use of restraints, and a physician order specified the application of a hand mitten to the resident's left hand. However, the care plan, initially created at admission, had not been updated since October of the previous year, despite facility policy requiring quarterly updates. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the care plan was overdue for revision and that any licensed nurse could perform updates. The facility's policies on comprehensive care planning and restraint use both required quarterly review and updates by the interdisciplinary team. The lack of timely care plan revision had the potential to result in the resident not receiving appropriate nursing interventions related to restraint use.