Failure to Care Plan and Obtain Orders for Required Arm Sling After Humerus Fracture
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive care plan and corresponding physician orders for a resident who required a left arm sling following a humerus fracture. The resident’s diagnoses included a left humerus fracture, chronic kidney disease, and type 2 diabetes. Hospital discharge documents dated 11/21/25 indicated the resident was fitted with a left arm sling due to the fracture. However, review of physician orders from 11/21/25 through 12/2/25 showed no order for a left arm sling. A five-day MDS assessment identified the resident as cognitively intact with a BIMS score of 13 and dependent on staff for dressing and transfers. The Resident Care Plan dated 11/27/25 documented a self-care deficit and fall risk with an intervention for one-person assistance with dressing, but it did not include the use of a sling or interventions specific to the left arm fracture. The nurse aide care card also lacked instructions that the resident was to wear a left arm sling at all times. A complaint filed on 1/2/26 reported that during a visit on 12/3/25, the resident was observed without the sling. In interviews, an LPN recalled that the resident had a sling that was to be worn all the time and stated that directions for sling use should have been on the physician’s order or the care plan. A nurse aide reported that the resident wore the sling all the time except when being changed, and that she learned sling directions from the therapist and believed they were on the care card, while also noting the sling sometimes came off with the resident’s independent movement. The COTA stated she was informed of sling orders by the OT and that such orders should have appeared on the physician’s orders, care plan, and care card. The DON acknowledged that directions for sling use should have been on the physician’s orders or the care plan and that the facility failed to follow its Care Plan Policy, which requires care plans to include instructions and services/treatments needed to provide effective, person-centered care.
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