Failure to Include Contractures in Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with contractures. Despite both residents having documented impairments and contractures in their medical records, assessments, and therapy notes, their care plans did not reflect these conditions. Staff interviews confirmed that both residents required assistance related to their contractures, such as help with eating and the use of splints or therapy interventions. However, the care plans lacked any mention of contractures or related interventions, contrary to facility policy and the residents' identified needs. Multiple staff members, including the MDS nurse, ADONs, and DON, acknowledged the presence of contractures and the importance of including them in care plans. The facility's own policies require care plans to address mobility and range of motion, including contractures, with specific interventions. Despite this, the care plans for both residents were not updated to include these needs, resulting in a failure to ensure that services were described and provided to maintain or improve the residents' physical, mental, and psychosocial well-being.