Failure to Revise Care Plan to Remove Unordered Abdominal Binder Intervention
Penalty
Summary
The facility failed to revise the care plan for a resident with a gastrostomy tube, resulting in the continued inclusion of an intervention for an abdominal binder despite the absence of a physician's order for its use. The resident, who was admitted with diagnoses including dysphagia following cerebral infarction and required tube feeding, had a care plan intervention stating that an abdominal binder should be used at all times, with removal only during care for skin inspection. However, review of the physician's orders confirmed there was no order for an abdominal binder, and multiple staff members, including an LPN and a CNA regularly assigned to the resident, reported never having seen the binder in use. The MDS Coordinator acknowledged that the abdominal binder intervention was mistakenly included in the care plan upon the resident's admission and was overlooked during the most recent quarterly review. The facility's policy requires that care plans be comprehensive, person-centered, and consistent with the resident's assessment and professional standards, but the care plan was not updated to reflect the resident's actual needs and physician orders. This resulted in a care plan intervention that was not implemented or medically indicated.