Deficient Care Planning for Restorative and Dementia Care
Penalty
Summary
The facility failed to accurately complete and update care plans for two residents, resulting in deficiencies related to care planning. For one resident, the care plan for the restorative nursing program (RNP) was not consistent with the intended schedule. The resident was supposed to receive passive range of motion (ROM) exercises to both upper and lower extremities on alternating days, but the care plan listed both as occurring on the same days. The resident reported not receiving the RNP daily as expected, and the restorative nurse confirmed the care plan needed revision to reflect the correct alternating schedule. Another resident was admitted with a diagnosis of traumatic brain injury and was cognitively intact according to the Minimum Data Set (MDS), with no documented diagnosis of dementia or Alzheimer's disease. However, physician notes indicated a diagnosis of dementia, and staff confirmed this diagnosis was present in the electronic health record. Despite this, there was no dementia care plan in place for the resident, and staff acknowledged that the MDS was incorrect and a dementia care plan should have been developed based on the diagnosis.