Failure to Update Care Plan After Resident's Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's care plan was reviewed and revised by the interdisciplinary team following a significant change in the resident's condition. The resident, who had a history of cerebrovascular accident with hemiplegia and dementia, reported pain in the left arm to a CNA, which was communicated to an RN. The following day, the resident again complained of pain, and swelling was observed in the left arm. The RN notified the physician, who ordered Tylenol and a STAT x-ray. The resident was subsequently transferred to the hospital with altered mental status, elevated blood pressure, and was later diagnosed with a fracture of the left proximal humerus. Despite these significant changes in the resident's condition, including new pain, swelling, and a hospital transfer for further evaluation, there was no documented evidence that the care plan was updated to reflect these developments. The existing pain management care plan had last been updated months prior and indicated the resident was stable with no complaints of pain. Interviews with facility staff confirmed that care plans are expected to be updated with changes in condition, but in this case, the care plan was not revised to address the resident's new symptoms and interventions.