Failure to Care Plan and Arrange Follow-Up for Olecranon Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan and to follow physician recommendations for a resident with a subacute-chronic olecranon fracture. The facility’s policy requires a comprehensive care plan with measurable objectives and timeframes to address each resident’s medical, nursing, mental, and psychosocial needs, including services identified in the comprehensive assessment. Resident #1, admitted with diagnoses including type 2 diabetes and chronic pain syndrome, had a Quarterly MDS showing a BIMS score of 06, indicating severe cognitive impairment. After rolling out of bed and falling on the left side, the resident was evaluated in a local ED, where a CT scan on 12/12/2025 showed a subacute to chronic olecranon fracture with distraction and mild rotation of the fracture fragment. A splint and sling were applied to the resident’s left arm, and discharge instructions directed the facility to schedule an orthopedic follow-up. Despite these instructions, review of the resident’s physician orders showed no orders entered for management or follow-up of the left olecranon fracture, and the comprehensive care plan contained no interventions related to the fracture or its management. The medical record did not show that an orthopedic follow-up appointment was ever scheduled or completed. In interviews, the resident reported having gone to the ED, receiving a splint and sling, and not returning to a doctor to have the elbow checked. The MDS nurse, responsible for updating care plans, stated she was not aware the resident had returned from the ED with a splint, sling, and an order for orthopedic follow-up, and acknowledged the care plan had not been updated. The ADON acknowledged that physician orders for care and follow-up of the fracture had not been entered and that the care plan should have been updated. The DON acknowledged that the resident did not receive orthopedic follow-up care and that care plan interventions were not updated.
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