Failure to Implement Comprehensive Care Plan for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place and properly executed for a resident, leading to the development and worsening of pressure ulcers. The resident, who was admitted with diagnoses including knee contractures, was observed without offloading boots, which were supposed to be on at all times as per the care plan. The boots were found on the floor, and staff members were unclear about their responsibility for ensuring the boots were worn, leading to the resident's feet resting directly on the mattress. The resident was observed to have a pressure ulcer on the left trochanter and a coccyx pressure ulcer, both of which were not properly documented or staged in the care plan. The left foot was initially documented as a hematoma but was later identified as a deep tissue injury (DTI). The care plan did not include updated interventions for the pressure ulcers, and there was no evidence of a root cause analysis or interdisciplinary team meetings to address the skin breakdown. Interviews with staff, including CNAs, a COTA, an LPN, and the wound nurse, revealed a lack of clarity and communication regarding the care plan and interventions for the resident's pressure ulcers. The Director of Nursing confirmed that the resident's Kardex indicated the need for offloading boots at all times, but this was not consistently followed. The facility's failure to implement and revise the care plan contributed to the resident's pressure ulcers not being properly managed or prevented.
Plan Of Correction
Element 1 Resident 7 continues to reside in the facility. The skin care plan was reviewed and updated to include the correct classification and staging of current wounds and include appropriate interventions to prevent and promote healing of wounds by the Director of Nursing/Designee by 3/14/25. Element 2 A one-time audit of current residents with wounds was completed to ensure their skin care plans have the correct classification and staging of current wounds and they include appropriate interventions to prevent and promote healing of wounds. This was completed by the Director of Nursing/Designee by 3/14/25. Element 3 The QAPI Committee has reviewed the Comprehensive Care Plan policy and has deemed it to be appropriate by 3/14/25. The Director of Nursing and/or designee educated the Wound Care Nurse and the licensed nurses on the Comprehensive Care Plan policy by 3/14/25 with emphasis on ensuring skin care plans have correct classification and staging of wounds and that they include appropriate interventions to prevent and promote healing of wounds. Nurse Aides were educated on checking resident kardex s and ensuring interventions are in place. This was completed by the Staff Development Coordinator/Designee by 3/14/25. Wounds will be reviewed weekly in standard of care meeting to ensure wounds are classified and staged correctly and interventions are in place to prevent and promote wound healing. Element 4 The Director of Nursing/designee will audit Skin care plans of residents with wounds weekly x4 weeks then monthly thereafter to ensure wounds are classified and staged correctly and interventions are in place to prevent and promote healing of wounds. Results will be reviewed monthly by the QAPI Committee until substantial compliance is achieved. The Administrator is responsible to maintain compliance.