Failure to Develop Comprehensive Care Plan for Resident with Ankle Fracture and Splint
Penalty
Summary
A deficiency was identified when the facility failed to develop an individualized, comprehensive care plan for a resident with multiple complex medical conditions, including end stage renal disease, diabetes mellitus type two, and chronic obstructive pulmonary disease. The resident was admitted with these diagnoses and later sustained a left ankle fracture, which was splinted during a hospital stay. Upon return to the facility, there were no physician orders for care of the left foot or splint, and the resident's care plan did not address the new fracture, the presence of the splint, or the required care for the affected limb. Interviews with facility staff, including the Assistant Director of Nursing and a Registered Nurse, confirmed that the care plan and medical record lacked documentation regarding the left ankle fracture and splint care. Review of facility policy indicated that the use of medical devices, such as splints, should be reflected in the care plan and corresponding orders. This omission was found during a review of 11 residents' care plans, affecting one resident, and was substantiated by medical record review, staff interviews, and policy review.