Failure to Develop and Implement Comprehensive Care Plan for Resident with Orthopedic and Behavioral Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs. Specifically, the care plan did not address the resident's orthopedic order for a left arm sling prescribed for comfort, nor did it include the resident's history of refusing care and medication. Despite multiple documented instances in the medical record of the resident refusing medications, care, and the use of the prescribed sling, these issues were not reflected in the care plan, leaving gaps in the documentation of measurable objectives and interventions tailored to the resident's needs. The resident in question was admitted with diagnoses including hemiplegia and cerebral infarction, resulting in impairment of one side of both upper and lower extremities. The resident was cognitively intact, as indicated by a BIMS score of 13, and had a documented order for a left arm sling to be used for comfort and healing. Nursing notes repeatedly documented the resident's refusals of care, medication, and the use of the sling, as well as his preferences for a specific type of sling. Interviews with staff confirmed that the resident's noncompliance and preferences were discussed in daily meetings, but this information was not incorporated into the care plan. Interviews with facility staff, including LVNs, the MDS Coordinator, the DON, and the Administrator, revealed a lack of clarity and follow-through regarding responsibility for updating care plans. While staff acknowledged that the resident's use of the sling and history of refusals should have been included in the care plan, this was not done. The facility's own policy required comprehensive care plans with measurable objectives and time frames to address all identified needs, but this was not followed in the resident's case.