Failure to Update Care Plan for Resident's Arm Sling Post-Hospitalization
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who returned from hospitalization with a left arm fracture. Despite physician orders requiring the resident to wear a stabilization arm sling, the care plan did not include any focus, goals, or interventions related to the use of the sling. Record reviews confirmed that the care plan was not updated to reflect the new care needs following the resident's return from the hospital. Observations showed the resident using a soft cast and sling, and interviews with nursing staff and the DON confirmed that the care plan lacked documentation for the prescribed sling, even though staff were aware of and assisted with the sling as ordered. The resident had a history of hemiplegia and required assistance with activities of daily living. The omission in the care plan was identified through review of medical records, staff interviews, and direct observation. The facility's own policy required that care plans be comprehensive and person-centered, including measurable objectives and interventions based on thorough assessment, but this was not followed in the case of the resident's new need for arm stabilization.