Failure to Develop Comprehensive Care Plans for ROM and Activity Needs
Penalty
Summary
Surveyors identified that the facility failed to develop comprehensive, individualized care plans addressing all assessed needs, including ROM/contracture management and activity preferences, for three residents. One resident with severe cognitive impairment, documented intracerebral hemorrhage, pulmonary hypertension, protein-calorie malnutrition, COPD, pain, and documented ROM impairment in one upper and one lower extremity was observed in a reclining wheelchair with a fully contracted left hand and no splints or washcloths in place for contracture management. The resident’s MDS showed dependence in ADLs and no ROM program in place, and the care plan dated several months earlier did not include any ROM/contracture management interventions or an activities care plan, despite an activity assessment indicating the resident enjoyed music, sitting outside, watching TV and movies, preferred to stay in the room, and preferred small group or in-room activities. Another resident, admitted earlier in the year, had documented diagnoses of legal blindness, anxiety disorder, and other psychotic disorders, with an MDS showing a BIMS score indicating intact cognition and a need for setup, clean-up, supervision, or touching assistance for various mobility and transfer tasks. The resident’s care plan entry regarding activity participation preferences was incomplete and not done, and the quarterly/annual activity assessment form was blank and unedited. A third resident with paralytic syndrome and acute respiratory failure with hypoxia had an MDS indicating moderate cognitive impairment and dependence for bed mobility and tub/shower transfers, but the quarterly/annual activities assessment was unedited and not completed, and there was no care plan addressing the resident’s activity preferences. Staff interviews confirmed that activity and social service assessments and related care plans were expected to be completed on admission and updated quarterly, and the facility’s care plan policy required an individualized comprehensive care plan based on the comprehensive assessment for each resident.
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