Failure to Include Leg Contracture in Person-Centered Care Plan
Penalty
Summary
Surveyors found that the facility failed to develop and implement a person-centered comprehensive care plan addressing a resident’s left leg contracture. Observation on 03/04/26 at 9:53 a.m. showed the resident’s left leg was contracted, bent at the knee with the left ankle positioned under the right knee. The resident’s care plan, dated 02/23/26, documented diagnoses including osteoarthritis of an unspecified hip, cerebral infarction (stroke), and aseptic necrosis of the left femur, and noted the resident required assistance with lower body dressing and a total lift for transfers. However, the care plan did not include any problem, goals, or interventions related to the resident’s left leg contracture, despite the facility’s policy requiring a comprehensive person-centered care plan that describes services to attain or maintain the resident’s highest practicable well-being. During interview, the resident reported that the leg became contracted at another nursing facility following a stroke, that they wore a compression sleeve on the left leg for comfort, and that they required pain medication to manage pain. Staff interviews confirmed the omission: a CNA stated they used care plans to guide resident care and acknowledged the resident’s contracture was not addressed in the care plan; an RN also stated the contracture was not listed on the care plan. The MDS coordinator and the DON each stated that the resident’s left leg contracture was not included but should have been included in the care plan. These observations and interviews demonstrated that the facility did not ensure the resident’s contracture was incorporated into a person-centered comprehensive care plan as required by facility policy.
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