Failure to Update Care Plan After Resident Fracture
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan to address a resident's newly diagnosed right humerus fracture following a fall. After the resident was found on the floor with a skin tear near her bed, an X-ray confirmed a nondisplaced fracture of the medial epicondyle of the right humerus. Despite this significant change in the resident's condition, the care plan was not updated to include the fracture, associated interventions, or measurable goals. The resident had a history of dementia with agitation, anxiety disorder, and required staff assistance with activities of daily living. She was also on hospice care, and her responsible party declined aggressive treatment for the fracture, opting for comfort measures. Orders for pain management were received and implemented, but the care plan continued to reflect only fall risk and did not address the new fracture or specify interventions related to the injury. Interviews with facility staff, including the DON and MDS nurse, confirmed awareness of the fracture and acknowledged that the care plan should have been updated to reflect this significant change. The facility's policy required care plans to be revised when there is a significant change in a resident's condition, but no acute or comprehensive care plan update was completed for the fracture. This omission resulted in a lack of documented guidance for staff on how to address the resident's new medical needs.