Failure to Develop Comprehensive Care Plan for AFO Brace Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with severely impaired cognition, functional limitations in both lower extremities, and a diagnosis of right-sided weakness following a stroke. Although the resident was prescribed a right ankle foot orthosis (AFO) brace to be worn when out of bed and in a wheelchair, the care plan, order report, and task documentation did not include instructions for the use of the brace. Staff interviews confirmed that while nursing assistants and LPNs had received education on the application of the brace, they were unable to locate written instructions or documentation in the resident's care plan regarding when and how the brace should be applied. Further review revealed that therapy staff had communicated the need for the resident to wear the AFO brace for more than four hours a day when in a wheelchair, with skin checks to be performed during application and removal. However, this information was not incorporated into the resident's care plan. The director of therapy acknowledged that it was her responsibility to ensure new therapy orders were added to the care plan, but this had not occurred. The lack of documented instructions and integration of therapy recommendations into the care plan resulted in a failure to provide a complete and measurable plan of care for the resident's needs.