Failure to Develop and Implement Comprehensive Care Plan for Wrist Splint
Penalty
Summary
A deficiency was identified when a resident with a history of palliative care, hemiplegia and hemiparesis of the left side following a cerebral infarction, and vascular dementia did not have a comprehensive, person-centered care plan addressing all of their needs. Specifically, the resident had a contracted left wrist and was provided with a wrist splint, but there was no documentation of physician orders for the splint, nor was the use of the splint included in the resident's care plan. The resident reported limited movement in the left hand and arm, and stated that he was supposed to wear the brace in the afternoon and evening, but had not worn it for approximately two weeks because CNAs had difficulty applying it. The resident clarified that he did not refuse the brace. Record review confirmed the absence of orders for the wrist splint and no care plan interventions related to the splint. Interviews with nursing staff and the DON confirmed that the brace was provided by the hospice nurse manager and was occasionally used to maintain comfort, but its use was not formally documented or care planned. The DON acknowledged that the care plan should have included all care being provided, including the wrist splint.