Failure to Develop and Implement Care Plans for ROM and Dental Needs
Penalty
Summary
The facility failed to develop and implement a person-centered care plan addressing both range of motion (ROM) and dental needs for a resident diagnosed with Cervical Disc Disorder with Myelopathy. The resident was discharged from occupational therapy with recommendations for cervical ROM exercises, but there was no evidence that these exercises were performed or documented. Interviews with facility staff, including the Director of Nursing, confirmed that there was no restorative nursing program in place at the time and no care plan related to cervical ROM for the resident. Additionally, the resident was observed to be edentulous and not wearing dentures due to pain, instead gumming food during meals. The resident reported needing new dentures, and staff interviews confirmed the absence of a care plan addressing dental needs, denture use, or the resident's preferences and complaints regarding dentures. The Minimum Data Set (MDS) did not accurately reflect the resident's edentulous status, and there was no documentation or care planning for non-compliance with denture use or for the resident's dental discomfort.