Failure to Care Plan Contractures and ROM Interventions for Hospice Resident
Penalty
Summary
The facility failed to develop and implement a care plan addressing limited range of motion and contractures for one resident with an impairment to the right middle finger. The resident was admitted with multiple diagnoses including dementia and a right middle finger impairment, and later had a physician’s order dated 7/8/25 for placement of a rolled washcloth in the right hand, with task completion documented by nursing staff on the treatment administration record. However, review of the resident’s care plans on 12/11/25 at 10:05 AM showed no care plan addressing the resident’s contractures or the rolled washcloth intervention. During an interview at 10:21 AM, the DON confirmed the absence of a care plan for the contractures and stated there was no care plan because the resident was on hospice. These findings were subsequently reviewed with facility leadership at the exit conference on 12/16/25 at 3:45 PM.
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