Failure to Develop and Update Care Plan for Resident with Hand Contractures
Penalty
Summary
The facility failed to create, revise, and update a comprehensive care plan in a timely manner for a resident with significant physical limitations. Specifically, the resident was observed with bilateral hand contractures and was using white knit tube stockings on both arms, but was not wearing hand splints. The resident required maximum assistance with eating and drinking and was non-verbal at the time of observation. Review of the electronic medical record revealed that there was no care plan addressing the use of hand splints or occupational therapy (OT) interventions related to the resident's limited range of motion. Further investigation showed that the OT staff had not participated in any care plan meetings with the interdisciplinary team since a specified date, and there was no care plan referencing the use of bilateral hand orthotics or splints. The OT evaluation and plan of treatment documented a diagnosis of contractures of the bilateral hands and wrists, with a goal for the resident to tolerate bilateral hand orthotics without skin changes. However, there was no evidence that the interdisciplinary team, including nursing, had created a care plan reflecting these OT goals or the use of the new air pump style splint, which also lacked a physician order.