Failure to Update Care Plan After Resident Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had sustained a fracture to her upper right arm. Despite the resident's significant medical history, including severe cognitive impairment, dementia, muscle wasting, and lack of coordination, the care plan was not updated to reflect the new diagnosis of an acute nondisplaced fracture of the right humeral neck following a fall. The resident was dependent on staff for multiple activities of daily living, and the omission was confirmed through record reviews and staff interviews. Interviews with facility staff, including the LVN, DON, and ADM, revealed that the fracture and change in condition should have been incorporated into the resident's care plan to ensure appropriate care. The facility's own policy required that care plans be updated to address all identified needs, including measurable objectives and interventions. However, the care plan did not reflect the resident's fracture, and staff acknowledged that this failure could result in staff not knowing how to manage the resident's new condition.