Failure to Develop and Implement Care Plan for Assistive Device Use
Penalty
Summary
The facility failed to develop and implement a care plan addressing the use of a rollator walker for a resident with end-stage renal disease on hemodialysis and diabetes mellitus type 2. Despite the resident being at risk for falls due to gait and balance problems, psychoactive drug use, and weakness, there was no individualized care plan in place for the safe use of the rollator walker. The resident's care plan only generally addressed fall risk but did not include specific interventions or measurable objectives related to the assistive device, as required by facility policy. On the day of the incident, the resident attempted to get up from the rollator walker on the outside patio, lost balance, and fell, resulting in an acute humeral neck fracture that required hospitalization. Documentation revealed that the physical therapy department had discharged the resident from services without completing an assessment or evaluation for rollator walker use, and there was no communication of recommendations to the nursing staff. The lack of a care plan and communication between therapy and nursing staff contributed to the resident's fall and injury. Interviews with the DON and occupational therapist confirmed that there was no care plan for the use of the rollator walker and that nurses were not made aware of the resident's needs regarding the device. Facility policies required comprehensive, person-centered care plans and documentation of assistive device use based on assessment, but these were not followed. The deficiency was further compounded by the absence of interdisciplinary communication and failure to adhere to established policies and procedures.