F0657

E

Failure to Revise Care Plan After Resident Returned With Fracture and New Treatment Orders

Gallup, New Mexico Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to revise a resident’s comprehensive, person-centered care plan after a documented change in condition following a hospital stay. The facility’s Person-Centered Care Plan Policy, revised 09/15/25, requires that the care plan be revised after each assessment and upon changes in the resident’s condition, and that the IDT review and revise the care plan to ensure safe and appropriate delivery of care. Record review showed that the resident was discharged from the hospital with a confirmed right scapular spine fracture with nonunion, was to return wearing a sling, receive orthopedic follow-up on 11/26/25, and be monitored for pain and mobility changes.

Despite these hospital discharge instructions, review of the resident’s care plan dated 12/02/25 revealed no revision to include the diagnosed fracture, no interventions for immobilization, no instructions for staff regarding assistance with transfers or mobility, and no pain-specific interventions related to the fracture. A CNA reported that the resident was supposed to use a sling but did not consistently wear it and continued to push himself up with the injured arm, and stated she had not been given any care plan direction or training about sling use or mobility precautions. The Administrator stated the care plan should be revised when a resident returns from the hospital with new diagnoses and treatment requirements, acknowledged he was unaware of the fracture, and indicated the DON was responsible for ensuring care plan updates. The Medical Director stated he was aware of the broken scapula and expected the facility to follow the hospital’s recommendations and care plan all interventions.