Failure to Implement and Update Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan with measurable objectives and timeframes for a resident with hemiplegia affecting the right dominant side and right hand contractures. The resident's care plan included an intervention to assist with applying a right resting hand splint daily to prevent complications such as contracture formation, embolism, and immobility. However, observations on multiple occasions revealed that the resident was not wearing the splint, and there was no documentation of the resident refusing the application of the splint. Interviews with staff indicated confusion regarding responsibility for the application of the splint, with the CNA stating that therapy staff were responsible, and the Physical Therapy Manager referencing restorative care and resident refusal, though no such refusal was documented in the care plan. The MDS Coordinator and DON acknowledged that care plan updates were necessary to ensure residents received appropriate care and that failure to update or implement the care plan could negatively impact the resident's condition. The facility's policy required care plans to include measurable objectives, timeframes, and ongoing updates, which was not followed in this case.