Failure to Develop Comprehensive Care Plan for Amputee Resident
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan (ICCP) for a resident who had a new left below knee amputation and was receiving wound care for a surgical site. This deficiency was identified during a survey when the resident, who was observed sitting in a wheelchair, mentioned receiving therapy on the left leg. The resident's medical record indicated diagnoses including acquired absence of the left leg below the knee, diabetes mellitus, repeated falls, and acute kidney failure. Despite these conditions, the ICCP did not include the left below knee amputation, surgical wound, or impaired skin integrity. The Director of Nursing (DON) confirmed that the surgical wound should have been noted in the admission assessment, physician orders, and included in the ICCP, with a focus on impaired skin integrity. However, the review of the ICCP revealed that these critical aspects were missing. The facility's policy, dated 9/1/24, mandates the development and implementation of a comprehensive person-centered care plan for each resident, consistent with their medical, nursing, and psychosocial needs as identified in the comprehensive assessment. This policy was not adhered to in the case of the resident with the new amputation.
Plan Of Correction
1. Resident affected by deficient practice: The facility failed to develop an individualized comprehensive care plan for a resident with a new NJ Exec Order 26.4b1 who was receiving care to a NJ Exec Order 26.4(b)(1). Resident #189 care plan was updated to reflect NJ Exec Order 26.4b1 related to NJ Exec Order 26.4(D). 2. Identifying other residents who could be affected by the deficient practice: Residents who are admitted to the facility with a surgical site could be affected by this deficient practice. Other residents with surgical sites were audited. No other residents with surgical sites were found. 3. Measures or systemic changes to ensure that the deficient practice does not recur: Unit Managers, Nursing Supervisors, and Licensed Nurses in-serviced on Comprehensive Care Plans to include surgical wound care by Director of Nursing. 4. Monitoring the continued effectiveness of the systemic change: Director of Nursing/designee will conduct audits of all new admissions to ensure accurate completion of comprehensive care plans for surgical sites/wounds weekly x 4 then monthly x 2. Results of the audit will be reviewed at the Monthly Quality Assurance Meeting and Quarterly over the duration of the audit process to ensure compliance and reassessed for further action.