Failure to Include Neck Pillow Intervention in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan with measurable goals and interventions for one resident, as required by their own policy and federal regulations. Specifically, the care plan for a resident with quadriplegia, aphasia, and dysphagia did not include documentation or interventions related to the use of a neck pillow/support, despite the resident having a neck flexion contracture and an order for the neck pillow. The care plan only addressed assistance with activities of daily living and promoting safety, omitting the specific intervention of the neck pillow. Staff interviews and record reviews confirmed that the resident's care plan did not reflect all necessary interventions for the contracted neck, as the use of the neck pillow was not included. The DON acknowledged that staff were expected to follow orders and care plans, and to document refusals, but confirmed the omission of the neck pillow from the care plan. This lack of comprehensive care planning placed the resident at risk for unmet care needs and not achieving their maximum practicable level of functioning.