Failure to Include Cold Therapy Device in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan that included all required elements for a newly admitted resident when using a comprehensive care plan in place of a baseline care plan. Specifically, the care plan did not address the resident's use of a cold therapy device, which was brought with the resident upon admission following a right shoulder replacement. The resident, who had diagnoses including high blood pressure, osteoporosis, and was receiving aftercare for joint replacement surgery, was assessed to have intact cognition. Documentation showed that the cold therapy device was in use, but the comprehensive care plan initiated at admission did not include information or instructions regarding its use. During interviews, the resident reported that the ice in the cold therapy device had been running out and expressed uncertainty about staff understanding of the device's operation, referencing a paper with information taped to her wall. The Nursing Home Administrator confirmed that the facility did not develop a comprehensive, person-centered care plan with all requirements for this resident, as required when a comprehensive care plan is used in place of a baseline care plan.