Failure to Implement and Document Care Plan Interventions for Two Residents
Penalty
Summary
The facility failed to implement care plan interventions for two residents as required by its own policies and procedures. For one resident with a history of osteoporosis, osteoarthritis, and dementia, the care plan specified the use of a left heel splint and required assessment of pedal pulses every shift following a documented left calcaneus fracture. However, there was no physician order for the splint in the resident's active orders, and staff interviews revealed confusion about who was responsible for applying and removing the splint. Additionally, there was no documentation that pedal pulses were being checked as required by the care plan. For another resident with diagnoses including abnormalities of gait and mobility and dementia, the care plan and physician orders required restorative nursing services (RNS) for ambulation with a front wheel walker three times per week. Despite these orders, the resident did not receive any RNS for an entire month. Staff interviews and record reviews confirmed that the missed services were due to miscommunication between nursing, restorative nursing aides, and rehabilitation staff, resulting in the resident not being ambulated as ordered. The facility's policy on care planning states that residents have the right to receive the services and items included in their plan of care. In both cases, the facility did not follow its own care planning procedures, leading to failures in providing ordered treatments and monitoring as specified in the residents' care plans.