Failure to Revise Care Plan to Include Positioning Device
Penalty
Summary
The facility failed to revise a resident's comprehensive care plan to include the use of a positioning device, specifically a sling, for a resident with a history of cerebral vascular accident (stroke) and hemiplegia. The resident was observed ambulating with a cane and had their left arm in a sling, but the care plan effective on two separate dates did not document the use of the sling as an intervention. The resident was noted to be cognitively intact and had limited physical mobility, yet the care plan interventions did not reflect the use of the sling. Interviews with the LPN/Nurse Manager and the Director of Nursing confirmed that the resident utilized a sling and that it should have been included in the care plan. The facility's policy requires ongoing assessment and revision of care plans as residents' conditions change, but this was not followed in this case. The deficiency was identified through observation, interview, and record review, and was cited under NJAC 8:39-11.2.