Failure to Update Care Plans for Leave of Absence and Contracture-Related Nail Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables that addressed all identified needs for two residents. For one resident with Type 2 diabetes mellitus, chronic osteomyelitis of the right foot and ankle, cellulitis of the right lower limb, and a history or active diagnosis of substance abuse, the resident was cognitively intact and had a physician’s order for an independent leave of absence (LOA). Although the facility’s LOA policy required that temporary LOAs be in accordance with the resident’s care plan and physician orders, the resident’s care plan did not include goals of care or interventions related to the independent LOA. The DNS confirmed that goals and interventions for residents with active LOA orders should be implemented into the care plan once the LOA order was approved, but this was not done for this resident. For a second resident with Type 2 diabetes mellitus with diabetic autonomic neuropathy, a contracture of the left hand, and schizoaffective disorder, bipolar type, the care plan identified refusal of care behaviors and included interventions such as re-approaching the resident, monitoring mood/behavior changes, and reporting to the medical doctor. Nail care was to be performed on bath days, but staff interviews revealed ongoing difficulty performing nail care due to the resident’s left hand contracture and resistance to having the hand cleaned or opened. An LPN reported being unable to adequately visualize or assess the nails and did not inform the nursing supervisor or provider, believing the issue was common knowledge. The DNS stated being unaware of the difficulties performing nail care, so no alternative nail care treatments were offered, despite facility practice requiring escalation to nursing supervisors or the provider when care tasks such as nail care could not be completed. This reflects a failure to implement care plan interventions related to physician notification for refusal of contracture-related care.
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