Failure to Develop Comprehensive Care Plans for Residents Using Mobility Equipment
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-specific care plans for two residents with limited mobility who required the use of assistive equipment. One resident, diagnosed with COPD, dementia, and malnutrition, had a physician's order to wear a right ankle brace when out of bed, but the care plan did not include goals or interventions related to the use of the ankle brace. Another resident, with diagnoses including high blood pressure, anxiety, and bipolar disorder, had a physician's order for bilateral resting hand splints, but the care plan similarly lacked goals and interventions for the use of these splints. Interviews with facility staff revealed confusion regarding responsibility for care planning related to braces and splints. The Registered Nurse Assessment Coordinator believed therapy staff entered care plans for splints, while the Rehabilitation Director clarified that the therapy department does not develop care plans for braces or splints. This lack of clarity contributed to the omission of necessary care plan components for both residents, resulting in a failure to meet regulatory requirements for comprehensive, individualized care planning.