Failure to Include Back Brace and Foot Protectors in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a back brace and bilateral foot protectors. The resident's admission assessment documented multiple fractures, muscle weakness, and functional limitations in both upper and lower extremities, with an intact cognitive status. Despite these needs, the care plan did not address the use of the back brace or foot protectors, even though the resident required the back brace when out of bed and the foot protectors while in bed. Observations confirmed the resident was using these devices as part of his care, and interviews with the resident and staff indicated that staff assisted with their application as needed. Interviews with nursing staff, the MDS Coordinator, the Unit Manager, and the DON revealed a lack of clarity regarding responsibility for updating care plans and whether such interventions should be included. The MDS Coordinator and DON both acknowledged that the back brace and foot protectors should have been included in the care plan, as they were interventions provided by the facility. However, the omission was not identified until the survey, and the facility's policy required all services identified in the comprehensive assessment to be included in the care plan with measurable objectives and timeframes.