Failure to Update Care Plan After Resident Sustained Acute Fractures
Penalty
Summary
The facility failed to update and revise the individualized, person-centered care plan for a resident following a significant change in condition. The resident, an elderly female with multiple complex medical diagnoses including muscle weakness, dysphagia, malnutrition, diabetes, mood disorder, Alzheimer's disease, and contractures of the lower extremities, sustained acute fractures of the right tibia and fibula. Despite the presence of an orthopedic boot and the resident being bedridden and non-weight bearing, there were no updates or new interventions added to her care plan to address the new fractures, the use of the orthopedic boot, or specific positioning and pain management needs related to the injury. Observation and interviews revealed that the resident and her family were unaware of how the injury occurred, and facility staff could not provide information regarding the onset of the injury or swelling. The hospital record confirmed the acute fractures and noted the resident's chronic contractures and immobility. Review of the care plan documentation showed no revisions or additions to address the resident's new care needs following the injury, and the chronic pain care plan did not include interventions for the acute fracture, positioning, or follow-up care.