Failure to Develop Comprehensive Care Plans for Residents with Prosthetic and Communication Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with bilateral below-knee amputations and a history of peripheral vascular disease, the clinical record showed the development of a stage 2 pressure injury on the left knee, which the resident attributed to a prosthesis being too tight. Despite the facility's policy requiring routine inspection of prosthetic devices and skin checks at contact points, the care plan did not include interventions for skin checks before or after wearing the prosthesis, nor did it address evaluating the fit and function of the prosthetic devices. This omission was confirmed by the lead wound care nurse, who acknowledged that these interventions were not included in the resident's care plan. Another resident, admitted with a diagnosis of legal blindness, did not have a care plan that addressed communication needs related to their visual impairment. Interviews with the Director of Nursing and the Regional Nurse confirmed that there were no care plan focuses, interventions, or goals documented for the resident's legal blindness. These findings demonstrate that the facility did not complete comprehensive care plans to meet the specific needs of these residents as required.