Failure to Revise Care Plan After Resident Refusal and Use of Restraint
Penalty
Summary
The facility failed to revise a resident's care plan after the resident refused to wear a prescribed brace and staff began using a compression wrap to secure the resident's left below-knee amputation stump to the wheelchair leg rest. Observations showed the resident was unable to remove the compression wrap and was seen pulling at it. Staff interviews revealed that the use of the compression wrap was not documented in the care plan, and refusals of the brace were not consistently recorded or reported. Staff also indicated that the use of the compression wrap had been ongoing and was not based on a documented care plan intervention. Review of the resident's comprehensive care plan showed no updates or interventions related to the use of the compression wrap as a restraint or the resident's refusal to wear the brace. The care plan only referenced the brace and monitoring under it, with no mention of the alternative intervention or associated risks. Facility policies required the care plan to be reviewed and revised by the interdisciplinary team and updated to reflect any restraint use, but these steps were not followed for this resident.