F0684

D

Failure to Ensure Orthopedic Follow-Up After Elbow Fracture

Las Cruces, New Mexico Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in which a resident with an olecranon (elbow) fracture did not receive the ordered follow-up care with an orthopedic surgeon. Emergency room documentation dated 09/18/25 showed the resident was diagnosed with an olecranon fracture, placed in a longarm splint, and instructed to follow up with an orthopedic surgeon. A provider progress note dated 09/23/25 documented the same diagnosis and stated the fracture was being followed by an orthopedic surgeon, with instructions to schedule an orthopedic follow-up and to continue soft casts for at least six weeks. A subsequent provider note dated 12/03/25 again referenced the olecranon fracture as being followed by an orthopedic surgeon and indicated that an X-ray could be repeated and the soft cast removed. Record review of the resident’s medical record revealed that, despite these recommendations and documentation, the resident did not have a follow-up visit with an orthopedic surgeon as ordered by the ER and the facility provider.

This failure to ensure the resident received the recommended orthopedic follow-up constituted the cited deficiency in providing appropriate treatment and care according to orders, preferences, and goals for one of six residents reviewed for accidents.