Failure to Assess, Obtain Orders, and Care Plan for Arm Immobilizer After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, and to complete required assessments and care planning for a resident following readmission from a general acute care hospital (GACH). The resident had diagnoses including peripheral vascular disease, type 2 diabetes mellitus, and a non‑pressure chronic ulcer on the right foot, and had severe cognitive impairment with dependence on staff for toileting hygiene, lower body dressing, and footwear. The resident’s history and physical documented that the resident did not have capacity to understand and make decisions. An SBAR form showed that on one date the resident was found unable to move the right arm and complained of severe pain with movement, and the PCP was notified and ordered transfer to the hospital via 911. Progress notes documented that the resident returned from the GACH later that evening with an arm splint and sling on the right arm due to a right elbow fracture and was experiencing discomfort in the affected arm. Staff interviews indicated that when an LVN started her shift the next day, she observed the resident back from the hospital with a cast on the right arm due to a radial head fracture, but on a later shift the cast was no longer present. The LVN reported being informed by the DON that the cast had been removed because an X‑ray had ruled out a fracture. The Director of Rehabilitation stated that the resident returned with an immobilizer on the right arm but that he did not conduct an assessment upon the resident’s return, explaining that because the fracture was ruled out, he did not consider this a change in condition requiring assessment. During interview and record review with the DON, it was confirmed that the resident returned from the GACH with an immobilizer on the right arm and that facility expectations upon readmission included notifying family and physician, documenting notifications, obtaining pertinent records from the GACH, and conducting comprehensive and skin assessments, as well as initiating and implementing a care plan for any change in condition. However, the record showed no documentation of a comprehensive assessment upon readmission, no physician order for use and monitoring of the right arm device, no resident‑centered care plan addressing the right arm device, and no monitoring of the device’s use. The facility’s policy on comprehensive person‑centered care plans stated that the interdisciplinary team reviews and updates the care plan when a resident is readmitted from a hospital stay, but this was not carried out for this resident.
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