Failure to Care Plan Contractures and Heel Protectors for High-Risk Resident
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple contractures and risk for pressure ulcers. Record review showed the resident had hemiplegia, hemiparesis, diabetic neuropathy, multiple documented contractures (left elbow, left hand, right and left knees), muscle wasting, dementia, and was dependent on staff for all ADLs, with frequent urinary and bowel incontinence and risk for pressure ulcers. The quarterly MDS documented severe cognitive impairment and functional limitations, and active physician orders included an air pressure-reducing mattress and bilateral heel protectors. However, the resident’s care plan for risk of pressure ulcer development did not include heel protectors/soft booties, and there was no care plan problem or interventions addressing the multiple contractures. During early-morning observation of incontinent care, surveyors noted the resident’s left elbow was bent close to the chest, the left hand and fingers were severely contracted, and both legs were flexed toward the chest with knees touching. The resident had a soft boot/heel protector only on the left foot and was on a low air loss mattress. When staff attempted to reposition and separate the knees for perineal care, the resident verbalized pain in the legs. Staff interviews confirmed that the resident frequently yelled out during care due to contractures and that staff sometimes had to stop and return later to complete ADLs. CNAs and LVNs described using pillows between the legs, rolled towels in the contracted hand, and soft booties or heel protectors, but these practices were not consistently documented as care plan interventions. Further interviews with the Director of Rehabilitation (DOR), MDS nurses, and the DON showed that therapy had previously provided contracture management, including splinting and use of a special bolster pillow behind the knees, and that the DOR had placed a blue bolster pillow behind the resident’s knees. The DOR stated the resident had severe contractures and experienced pain with minimal movement. CNAs and nursing staff were aware of the contractures and described techniques to position the resident and use the special bolster pillow and boots to reduce skin-to-skin contact and prevent worsening contractures and skin breakdown. Despite this, the MDS nurses and DON acknowledged that active contractures should have been care planned and that the care plan was intended to reflect the resident’s needs, goals, and interventions, but the resident’s contractures and ordered heel protectors were not included in the comprehensive care plan as required by facility policy.
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