Failure to Accurately Assess and Care Plan for Resident's Chronic Shoulder Injury
Penalty
Summary
The facility failed to ensure that a resident's assessment was accurate and reflective of her status at the time of admission. The resident, who had a history of acute respiratory failure, generalized muscle weakness, tracheostomy status, and dysphagia following a cerebral infarction, was admitted without a shoulder sling despite a documented chronic left humerus fracture. The admission Minimum Data Set (MDS) did not indicate any upper extremity impairment, and the care plan lacked goals or interventions related to the resident's shoulder injury. Therapy evaluations, however, identified the chronic fracture and recommended precautions, including the use of a sling for comfort, but this information was not incorporated into the nursing assessments or care plan. Multiple staff interviews revealed that nursing staff were unaware of the resident's shoulder injury upon admission and did not observe a sling in use. Certified Nursing Assistants (CNAs) described the resident as nonverbal, with limited mobility and a left arm that hung limply or swelled, but did not recall a sling being used. Nursing staff relied on limited information from admission paperwork and did not routinely access therapy notes, which were documented in a separate system. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the resident's shoulder injury was not identified in the initial assessment or care plan, and that the information was not present in the hospital facesheet or diagnoses list at the time of admission. The deficiency was further evidenced when, during routine care, staff observed the resident's left shoulder appearing out of place, prompting an x-ray and subsequent order for a sling. The lack of accurate and thorough assessment upon admission, incomplete review of hospital records, and poor communication between therapy and nursing staff led to the omission of critical information regarding the resident's chronic shoulder injury. This resulted in the resident not receiving appropriate interventions, such as the use of a sling, until the issue was later identified through observation and follow-up imaging.