Failure to Update and Revise Care Plans for Positioning and Behavioral Interventions
Penalty
Summary
The facility failed to update and revise the care plans for two residents, resulting in deficiencies related to position, mobility, and behavioral management. For one resident with a history of stroke, hemiplegia, and foot drop, the care plan included the use of a left leg brace (AFO) for positioning and protection. However, there was no provider order for the brace, and therapy assessments determined the brace was not clinically indicated since the resident was no longer ambulatory. Despite this, the care plan continued to list the brace as an intervention, and staff interviews revealed inconsistent knowledge and application of the intervention. The resident reported discomfort and refusal to wear the brace, and therapy staff were unaware of its continued use, indicating a lack of communication and care plan updates based on current assessments and resident needs. For another resident with moderate cognitive impairment and a history of resident-to-resident aggression, the care plan included interventions to prevent physical aggression, such as specific seating arrangements during meals and activities. Observations showed the resident was seated within arm's reach of other residents, contrary to the care plan interventions. Staff interviews revealed a lack of awareness of the care plan's specific interventions, and the DON was not aware of the resident's history of aggressive incidents or the care plan requirements. The care plan was not updated to reflect the resident's current behavior status or to discontinue interventions that were no longer appropriate. The facility's policy required care plans to be developed, reviewed, and revised based on comprehensive assessments and to be updated when problems, goals, or approaches were no longer appropriate. In both cases, the facility did not ensure care plans were accurately updated to reflect current clinical indications, resident preferences, and behavioral status, leading to discrepancies between care provided and documented interventions.