Failure to Implement Comprehensive Care Plan for Pressure Sore Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident identified as at risk for skin breakdown due to decreased mobility. The resident, who was admitted with dementia and severe cognitive impairment, required staff assistance for activities of daily living. Despite these needs, the care plan did not include specific and individualized interventions for pressure sore prevention from June 6, 2024, to December 12, 2024. This lack of preventative measures led to the development of pressure-related skin issues, including a non-blanchable area on the resident's left heel and a bruise on the great toe. The deficiency was confirmed during a staff interview, where the Director of Nursing acknowledged the failure to include preventative interventions tailored to the resident's risk for pressure sore development. Clinical documentation revealed that treatment orders for the left heel and first toe were only initiated after the skin issues were identified, indicating a lapse in proactive care planning. Preventative measures such as repositioning, use of pressure-relieving devices, or routine skin assessments were not documented prior to the development of the noted skin issues.
Plan Of Correction
- A17 care plan updated to include skin care interventions. - Current review of residents care plans related to potential or actual pressure injuries completed. In addition, the review will include reviewing and revising current residents for person centered care to meet each individual resident needs. After initial review care plans the facility will make updates with admissions, readmissions, quarterly, annually and PRN. - Policy entitled, "Comprehensive Person-Centered Care Planning", and (NEED SKIN CARE POLICY), reviewed for any updates. Nursing staff re-educated on both policies. - DON or designee will conduct weekly audits on care plans x 4, then monthly x 2. Audits will be presented at the monthly QAPI committee for ongoing oversight.