Failure to Implement Care Plan Positioning Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement person-centered care plan approaches for a resident with multiple sclerosis, seizure disorder, and paraplegia. The resident was assessed as cognitively intact but dependent on staff for mobility and activities of daily living, including positioning in bed and wheelchair. The care plan specified the use of a lateral support, such as a wedge cushion, to maintain upright positioning in the wheelchair. However, observations revealed the resident was repeatedly found leaning heavily to the left side in the wheelchair, with only a loosely folded blanket in place that did not provide adequate support. The resident expressed discomfort and stated that the wedge cushion was not available, and staff interviews confirmed the wedge cushion should have been in use according to the care plan. Further investigation showed that the care plan, including the use of the wedge cushion, was documented and accessible to staff. Despite this, the appropriate positioning device was not consistently implemented, resulting in the resident's inability to maintain an upright position and discomfort. The Director of Nursing confirmed that staff are expected to follow resident care plans, but in this instance, the care plan interventions were not properly carried out.