Failure to Update Care Plan for Resident's Prosthetic Leg
Penalty
Summary
A deficiency was identified when the facility failed to revise and update a resident's care plan to reflect the use of a prosthetic leg. The resident, who had a below-the-knee amputation of the left leg and was severely cognitively impaired, was consistently observed wearing a prosthetic leg and required daily assistance from nursing staff to put it on. Despite these observations and staff interviews confirming the resident's regular use of the prosthesis, the care plan only addressed assistance with activities of daily living (ADLs) related to the amputation and did not mention the prosthetic leg or provide guidance for staff regarding its use. The resident's clinical record and Minimum Data Set (MDS) assessment also failed to indicate the presence or use of a limb prosthesis, even though the resident had been using it for several years. Multiple staff members, including the MDS Coordinator, LPN, and CNA, acknowledged the resident's use of the prosthetic leg and their involvement in assisting with it. The Assistant Director of Nursing confirmed that the care plan should have included information about the prosthesis to provide direction for CNAs. Facility policy required comprehensive care plans to be reviewed and updated at least quarterly or more often if the resident's condition changed, but this was not done in this case.