Failure to Update Care Plans for Pressure Injury and Discontinued Oxygen Therapy
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident who developed a new sacral pressure injury. The resident, who was admitted for rehabilitation following hip surgery, returned from the hospital with a newly identified deep tissue injury (DTI) to the sacrum. Despite the initiation of treatment for the DTI, the care plan was not updated to include this new condition. Interviews with the treatment nurse and the Director of Nursing confirmed that the care plan should have been revised to reflect the new skin integrity concerns, but it was not. Additionally, the facility did not update the care plan for another resident whose oxygen treatment had been discontinued. The care plan still included an intervention for oxygen administration, even though the physician's order for oxygen therapy had ended. The LPN and MDS Coordinator acknowledged that the care plan should have been updated to resolve the intervention for oxygen administration, but it remained in the current care plan.