Failure to Develop Comprehensive Care Plan for Wound Care
Penalty
Summary
Kearsley Rehabilitation and Nursing Center was found to be non-compliant with the requirements for developing and implementing a comprehensive care plan as per 42 CFR Part 483, Subpart B. The facility failed to create a care plan addressing wound care for a resident, identified as Resident R1, who was at risk of developing pressure ulcers. The resident was admitted with conditions including cerebral infarction, severe protein-calorie malnutrition, and adult failure to thrive. Despite these conditions, the care plan did not include measures for a full-thickness abrasion on the resident's right dorsal foot. The facility's policy mandates that an interdisciplinary team develop an individualized comprehensive care plan within seven days of completing the Resident Assessment (MDS). However, a review of Resident R1's clinical records revealed that the care plan did not address the abrasion on the right dorsal foot, which was identified during a wound assessment. The wound assessment recommended specific treatments and preventative measures, such as cleansing with normal saline, applying medical-grade honey, and securing with bordered foam, but these were not incorporated into the care plan. Interviews with staff, including the Director of Nursing, confirmed the omission of the abrasion in the care plan. The facility's failure to include this critical aspect of wound care in the resident's care plan was a significant oversight, as it did not align with the facility's policy or federal regulations. This deficiency highlights a lapse in ensuring that the resident's medical and nursing needs were comprehensively addressed in their care plan.
Plan Of Correction
1. R1 no longer resides in the facility. 2. An Initial audit will be completed of all current residents in the facility with wounds to assure the care plans include current skin alterations and appropriate interventions. 3. The Director of Nursing will educate the facility wound nurse on the process and expectations of reviewing and updating care plans to ensure they include all skin alterations and appropriate interventions with new, changed, or resolved skin alterations. 4. NHA or designee will conduct weekly audits for 4 weeks or until compliance is met, to ensure residents who have wounds or skin alterations have a care plan in place that addresses current wounds or skin alterations. Audits will be reviewed by the QAA Committee. The QAA committee will determine continued audits.