F0656

D

Failure to Integrate and Implement Contracture and Wandering Interventions in Care Plans

Houston, Texas Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents whose needs had been identified in their assessments. For one male resident with Alzheimer’s disease, parkinsonism, stroke history, muscle weakness, and dependence in ADLs, the comprehensive assessment and care plan identified bilateral hand contractures and risk for skin breakdown, pain, and worsening contractures. The care plan interventions focused on keeping contractured areas clean and dry, providing PROM without forcing the joints, monitoring for pain and stiffness, and providing medications and treatments as ordered. However, the resident’s physician orders included a restorative nursing program that might have included a left resting hand splint and specific ROM and stretching exercises to prevent further contractures, and these splint/hand device interventions were not incorporated into the care plan.

Observations and interviews showed that the ordered hand splint/hand roll interventions were not consistently implemented. During observation, the resident was noted to have contractures in both hands with no splint or hand roll in place, and the resident reported that staff applied the devices only when they wanted and that he had not received them that day. The assigned RN stated he had not seen any hand roll in place, acknowledged the resident was supposed to have one, and indicated that restorative aides or CNAs were responsible for applying them. CNAs and restorative aides confirmed the resident was supposed to have “carrots” or rolled towels in both hands for specified on/off intervals, but reported that the devices were not present in the room at times, that they relied on restorative aides or CNAs to apply them, and that documentation of this care was inconsistent. Facility leadership, including the DON, ADON, and MDS Coordinator, acknowledged that the hand device intervention was not on the care plan, that restorative documentation was not integrated into the electronic plan of care, and that they could not locate documentation showing the ordered intervention had been consistently provided.

The deficiency also involves a female resident with dementia with psychotic disturbance, gait impairment, lack of coordination, altered mental status, restlessness, and agitation, who had severe cognitive impairment (BIMS score of 0), fluctuating inattention and disorganized thinking, and documented wandering behavior. Her care plan identified ADL deficits, need for staff to anticipate needs and provide prompt assistance, limited assistance for locomotion, supervision for walking, PROM as needed, and a history of unintentionally walking into objects. Interventions included frequent checks, maintaining safety during increased wandering, offering engaging activities, reducing environmental stimuli, using communication tools she could understand, and addressing her history of removing footwear. Despite these care-planned needs, the resident experienced an unwitnessed fall in the dining room after wandering, later presenting with a hematoma and discoloration on the right side of the face that required hospital evaluation.

Subsequent observation showed the resident ambulating independently with frequent brief losses of balance, not responding verbally, and continuing to walk away from staff attempts to assist. Staff interviews indicated that CNAs and nursing staff recognized the resident as nonverbal, continuously walking, not remaining seated, and at high fall risk, and that she required staff to watch her while walking. However, staff also reported there were no specific interventions beyond general supervision and non-skid socks to address her constant movement and wandering, and one CNA was unsure whether the care plan specifically included supervision interventions. Leadership interviews confirmed that staff were expected to follow care plans, that the resident was care planned for supervision due to wandering and fall risk, and that failure to follow or individualize care-planned interventions could result in residents not receiving necessary services. The care plan was only updated after the fall to add non-skid socks, indicating that at the time of the incident, the care plan and its implementation did not fully address the resident’s persistent wandering and supervision needs as identified in her assessments.