Failure to Develop Individualized Mobility Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing impaired mobility for a resident with a history of left-sided paralysis and weakness. During a complaint survey, it was found that the resident was dependent on staff for activities of daily living, including mobility and transfers. Despite this, there was no documented evidence that a resident-specific care plan was created to address the resident's mobility needs or to outline the interventions implemented to assist with mobility. The deficiency was identified through a review of medical records and care plans, as well as interviews with facility staff. The Assistant Director of Nursing confirmed that the care plan did not adequately address the resident's mobility needs after reviewing the documentation. The lack of a comprehensive, individualized care plan for mobility was observed in one of four residents reviewed for mobility needs during the survey.