Failure to Develop Care Plan for Resident’s Leg Prosthesis
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan addressing a resident’s left leg prosthesis. Surveyors observed the resident, who had an above-the-knee amputation of the left leg, sitting in a wheelchair with the prosthetic leg leaning against the bed on multiple occasions. The resident reported that there was something wrong with the prosthetic leg and indicated he used to wear it. Staff interviews confirmed that the resident had previously worn the prosthesis daily, sometimes with staff assistance for putting it on and taking it off, and that he had worn it during therapy from December 2025 through February 2026. Record review showed that the resident’s admission MDS, dated 12/15/2025, documented moderate cognitive impairment and diagnoses including hypertension, diabetes, and acquired absence of the left leg, but did not indicate the presence of a limb prosthesis. The resident’s care plans, reviewed on 03/23/2026, lacked any plan of care or interventions related to the prosthetic leg. The MDS Coordinator stated she was responsible for starting baseline and admission care plans and updating them based on new orders or assessments, and acknowledged there should have been a care plan for the prosthetic leg. Facility policy required comprehensive care plans to be reviewed and updated at least quarterly and more often as needed based on changes in the resident’s condition.
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