Care Plan Not Updated After Resident's Clavicle Fracture
Penalty
Summary
The facility failed to revise the comprehensive care plan to accurately reflect the current status of a resident following a significant change in condition. The resident, who has diagnoses including hypertension, non-Alzheimer's dementia, anxiety disorder, and depression, was found on the floor after self-transferring from a wheelchair and subsequently diagnosed with a right clavicle fracture. The resident's care plan did not include the new diagnosis of a fractured right clavicle or the updated order for weight bearing as tolerated (WBAT) to the right upper extremity, despite documentation in the electronic health record and physician's orders. The resident's care plan continued to list interventions related to fall risk and mobility, but failed to address the specific needs and interventions required following the clavicle fracture and the new WBAT order. Staff interviews and facility policy review confirmed that the care plan should have been updated to reflect these changes in the resident's condition, as required by facility policy and regulatory guidelines.