Failure to Update Care Plan for Healed Pressure Ulcer
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident 29, to reflect changes in her care needs. The facility's policy requires that an individualized person-centered plan of care be established and updated by the interdisciplinary team in accordance with state and federal regulatory requirements. A quarterly Minimum Data Set (MDS) assessment indicated that Resident 29 was cognitively impaired, dependent on staff for activities of daily living, and had diagnoses including dementia and high blood pressure. A consult note from a wound doctor confirmed that Resident 29 had no open wounds as of January 7, 2025. However, the current care plan, dated July 9, 2024, still listed a pressure ulcer on the resident's right heel. An interview with the Director of Nursing confirmed that the pressure ulcer was healed and the care plan should have been discontinued.
Plan Of Correction
1. The identified right heel care plan resolved at time of survey. 2. Facility pressure ulcer care plans reviewed for goal dates or need of resolution. 3. The Director Of Nursing/Designee will educate licensed staff on- Plan of Care Policy and document education. 4. Audits will be completed of care plans on residents with pressure ulcers for goal dates to review and update plan of care weekly x 8 weeks. Findings will be monitored by the Executive Director and reported to Quality Assurance Performance Committee for additional oversight.