Failure to Revise Care Plan After Fall-Related Compression Fracture and Pain
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan following a significant change in condition related to pain. The resident was admitted with active diagnoses including cancer, COPD, and an anxiety disorder, and had intact cognition as evidenced by a BIMS score of 14/15. An incident report documented that at 3:00 a.m. the resident called out to staff after a fall, and staff found the resident on her bed with a large hematoma and abrasion on the middle/lower back, measuring approximately one inch in height and three inches in length, with areas of missing skin and slight bleeding. The resident reported pain at a level of 6 on a 0–10 scale. An x‑ray report later documented a compression fracture of the upper end plate of the L1 vertebra associated with trauma and severe localized pain. Despite this new injury and ongoing pain, review of the resident’s care plan showed it was not updated to address pain post‑incident or to include interventions such as warm compresses. The facility’s Comprehensive Care Plans policy required that the comprehensive care plan be reviewed and revised by the interdisciplinary team as needed with any changes in the resident’s plan of care, and the Pain Management policy required that pain management interventions, including non‑pharmacological measures such as cold compresses, be incorporated into the comprehensive care plan and revised if pain was not adequately controlled. The DON confirmed that no interventions were added to the care plan regarding non‑pharmacological pain interventions, assessment of pain from the fracture, or warm compresses, and acknowledged that the care plan should have been updated.
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