Failure to Update Care Plan After Change in Condition With New Hip Pain
Penalty
Summary
Surveyors identified that the facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and interventions following a change of condition for one resident. The resident was admitted with diagnoses including age-related osteoporosis, unspecified dementia, and essential hypertension. An MDS dated 11/24/2025 documented that the resident had severely impaired cognitive skills for daily decision-making. On 2/9/2026, a Change of Condition (COC) Evaluation documented that the resident complained of right hip pain, was given Tylenol, and that the attending physician was notified and ordered a right hip x-ray at 2:45 p.m. During interviews and concurrent record review, RN 1 confirmed that no care plan was created to address the resident’s right hip pain following the COC on 2/9/2026 and stated that a care plan should have been initiated so staff would be aware of interventions to address the change of condition. The DON similarly stated that a care plan is a list of care and services to be provided for residents and acknowledged that a care plan should have been created after the COC, but the resident’s care plan did not include the right hip pain. The DON stated that the facility failed to ensure the resident had a care plan after the COC that addressed the resident’s right hip pain. Review of facility policies showed that the Care Planning policy required a comprehensive, person-centered care plan based on assessed needs, and the Change of Condition Notification policy required a licensed nurse to update the care plan to reflect the resident’s current status.
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