Failure to Include Assistive Device Care in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically omitting care instructions for a right leg brace and a right foot PRAFO boot. The resident, who had a history of right knee replacement, post-surgical infection, reduced circulation in the right leg, heart disease, and arthritis, was observed with a dressing and a brace on her right lower leg. She reported previous knee surgery with subsequent infection and additional wounds on her right leg. Record review showed the resident had nine wounds on her right foot and lower leg, including wounds attributed to a medical device. The care plans in place addressed pressure ulcers but did not include interventions or instructions related to the right leg brace or the right foot PRAFO boot. Interviews with the wound nurse confirmed that while physician orders existed for the use and monitoring of the PRAFO boot, these were not reflected in the resident's care plan or Kardex. Additionally, progress notes did not mention the right knee brace or PRAFO boot. Facility policy required that recommendations for assistive devices be based on comprehensive assessment and documented in the care plan, but this was not done for the resident's leg brace or foot boot, resulting in a lack of documented guidance for staff on their application and monitoring.