Failure to Develop Person-Centered Care Plan for Limited Range of Motion and Device Non-Compliance
Penalty
Summary
The facility failed to develop a person-centered care plan to address a resident's limited range of motion in the left upper extremity and non-compliance with a physician-ordered therapeutic device. The resident, who had a history of cerebrovascular accident (stroke) and depression, was documented to have moderate cognitive impairment and impairment of the left upper extremity. Physician orders and occupational therapy recommendations specified the use of a soft palm roll to the left hand at all times, except during range of motion, hygiene, and skin checks, to maintain skin integrity and prevent further contracture. Despite these orders, observations revealed the resident was frequently found without the soft palm roll in place, and staff confirmed the resident often removed the device using her right hand. Review of the resident's care plan showed it did not address the limited range of motion or the resident's non-compliance with the prescribed soft palm roll. Interviews with staff, including an LPN and the DON, confirmed the resident's non-compliance and the absence of a care plan to address these issues. The Nursing Home Administrator was unable to provide documentation of a care plan that included interventions for the resident's limited range of motion or strategies to address non-compliance with the therapeutic device, resulting in a deficiency under nursing services regulations.