Failure to Implement Comprehensive Care Plan for Resident with Leaf Sensor Device
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed all of a resident's assessed needs upon admission with a medical device, specifically a Leaf Sensor. The resident was admitted and readmitted with multiple diagnoses, including metabolic encephalopathy, type II diabetes mellitus, actinic keratosis, and rosacea. The resident's Minimum Data Set indicated moderate cognitive impairment and a need for moderate assistance with activities of daily living. The Braden Scale assessment showed a mild risk for pressure ulcers, and the resident was admitted with a Leaf Sensor on the mid-chest, with a physician's order to reinforce the sensor with Tegaderm if it became dislodged. Despite the care plan identifying the presence of the Leaf Sensor and the associated risk for infection and skin breakdown, staff interviews and record reviews revealed that key interventions were not implemented. Certified Nursing Assistants and nursing staff were not adequately informed or trained on the care and purpose of the Leaf Sensor. There was no documentation or evidence that the resident's skin integrity was assessed under the device, nor were pain assessments conducted as required by the care plan. Staff also did not document any reinforcement of the Tegaderm, and the monitoring device associated with the Leaf Sensor was not present in the facility during the resident's stay. The Director of Nursing and Administrator confirmed that there was no specific policy or procedure for the Leaf Sensor device, and that staff relied on general manufacturer guidelines. However, these guidelines required periodic inspection of the skin under the sensor for irritation or infection, which was not performed or documented. The lack of assessment and documentation regarding the resident's skin integrity and pain at the sensor site constituted a failure to follow the comprehensive care plan and physician orders, resulting in a deficiency.