Failure to Develop and Implement Comprehensive Care Plan for Contracture Management
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized care plan for a resident with a right hand contracture. Despite the resident's admission with diagnoses including right hand contracture, cerebral infarction, and muscle weakness, and documentation in the Minimum Data Set (MDS) assessment indicating severe cognitive impairment and upper extremity range of motion (ROM) impairment, there was no care plan addressing the contracture or limited ROM. Observations confirmed the presence of a contracture, and the occupational therapy (OT) discharge summary recommended specific interventions, such as a right resting hand splint and a left palm pillow, with a detailed wear schedule. However, these interventions were not reflected in the resident's care plan. Interviews with facility staff, including a CNA, nurse, unit manager, and DON, revealed a lack of awareness and documentation regarding a care plan for the resident's contractures. The CNA and nurse acknowledged the use of splints for the resident, but the nurse was unsure if a care plan existed. The unit manager confirmed that care plans are updated at least quarterly or with changes in condition, but upon review, found no care plan related to the resident's contractures or limited ROM. The DON also confirmed that such a care plan should have been in place.