Failure to Develop Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address the specific needs of two residents. For one resident with a history of cerebral infarction and a documented functional limitation in range of motion on one side, there was no care plan in place to address the risk for contracture or the need for range of motion (ROM) exercises, despite the resident being observed with her left leg bent and unable to straighten it. The resident also reported not receiving ROM exercises or splinting, and the MDS assessment confirmed the functional limitation. For another resident with Type 2 Diabetes Mellitus who required partial to moderate assistance with self-care, there was no care plan developed to address fingernail care, even though the resident was observed with excessively long fingernails and a dark brown substance under the nail beds. The MDS nurse confirmed that the care plans for both residents did not address these specific needs and acknowledged that these omissions should have been included to direct resident-specific care.