Failure to Develop Resident-Centered Care Plan for Pain, Mobility, and ADLs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, resident-centered care plan addressing pain management, mobility deficits, and ADL care for a resident with significant functional and cognitive impairments. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, musculoskeletal symptoms, and neurologic symptoms such as motor dysfunction. A History and Physical documented that the resident lacked capacity to understand and make decisions, and an MDS assessment showed severe cognitive impairment and dependence on staff for multiple ADLs, including dressing, toileting, transfers, mobility, oral hygiene, bathing, and dressing tasks. Therapy documentation further identified extensive functional limitations. A PT progress note indicated the resident required maximal assistance for bed mobility and sitting balance, with a need for upper extremity support. An OT progress note documented poor sitting balance during ADLs, also requiring maximal assistance and upper extremity support. Despite these findings, review of the resident’s care plans showed there were no care plans developed for pain management, mobility deficits, or ADL care, even though the facility’s policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet physical, psychosocial, and functional needs. Staff interviews confirmed ongoing pain complaints and the absence of appropriate care planning. CNAs reported that during ADL care, particularly when putting on the resident’s shirt or moving the right arm, the resident would moan, say “ouch,” and complain of pain, and that charge nurses had been informed, though dates and names could not be recalled. A family member stated they observed the resident having pain when the right arm was touched or moved and had posted a note above the bed reminding staff to be mindful of the painful, weaker side. Another CNA stated the resident’s complaints of right arm pain with movement could indicate a possible fracture needing assessment. The MDS nurse and DON both acknowledged that there were no care plans for mobility, ADLs, or pain, and stated that such care plans should have been developed and that nurses were responsible for creating and using these plans to guide care.
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