Failure to Address Dressing Assistance in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to develop a comprehensive care plan that addressed the specific assistance required for dressing for one resident. The resident, who had a history of hemiplegia and hemiparesis following a stroke, pain, major depressive disorder, and hypertension, was assessed as cognitively intact and required partial to moderate assistance with lower body dressing and personal hygiene according to the Minimum Data Set (MDS) and occupational therapy (OT) discharge summary. However, the resident's care plan only addressed personal hygiene and did not specify the type or amount of assistance needed for dressing. Interviews with the resident revealed that he was not receiving the help he needed from staff, and a CNA confirmed that the care plan did not address the resident's dressing needs. The Director of Nursing stated that therapy recommendations are supposed to be communicated to nursing staff for care plan updates, but was unaware of the OT's recommendations for this resident. The lack of inclusion of the OT's recommendations and the failure to update the care plan resulted in the resident's dressing needs not being properly addressed.