Failure to Care Plan for Hand Weakness and Oral Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables for a resident’s identified clinical issues. The resident, admitted in early 2026 with osteoarthritis of the knees and an anxiety disorder and assessed as having moderate cognitive impairment on the MDS dated 1/9/26, reported decreased strength and nerve issues in the left hand, with the thumb observed to be overextended backwards. A physician’s note dated 1/7/26 documented the resident’s complaints of left hand thumb weakness. Despite this, review of the resident’s current orders and care plans showed no monitoring orders or care plan addressing the left hand problem. The same resident also had an oral issue involving a cracked molar tooth with sharp edges that caused sores on the tongue. A progress note dated 1/27/26 documented the resident’s ongoing concern with the cracked molar that was bothering her and causing sores on her tongue. During observation and interview, the resident demonstrated an ulcer on the right side of the tongue, approximately 1 cm wide and 2 cm long, and stated that it developed after the tooth broke and that nobody was looking at or monitoring the progression of the ulcer. Review of the care plan and orders revealed no monitoring orders or care plan for the tongue ulcer. The DON confirmed the facility was aware of the resident’s left hand and tongue issues and stated he expected these issues to be monitored and care planned, which was not done, contrary to the facility’s policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes for each resident’s needs.
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