Failure to Update Care Plan for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were reviewed and revised in a timely manner for a resident with pressure ulcers. Specifically, the care plan for a resident, who had a history of [DIAGNOSES REDACTED] and required maximum assistance with rolling in bed, was not updated to include a new intervention when staff observed the resident moving their legs frequently while in bed. The care plan initially documented an intervention to float the resident's heels, but this was not effective as the resident was observed with their heels directly on the mattress on multiple occasions, and no alternative interventions such as heel booties or an air mattress were provided. During interviews, it was revealed that the nursing staff, including an LPN, were aware that the current intervention of using pillows to float the resident's heels was ineffective due to the resident's movements. However, they did not report this issue to the Nurse Manager or suggest alternative interventions. The facility's policy required that care plans be reviewed and updated regularly, especially with changes in the resident's condition, but this was not adhered to in this case, leading to the deficiency.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Resident # 68 comprehensive care plan was reviewed and revised on 3/8/25 to reflect an air mattress for pressure relief of her heels. The resident was monitored for 5 consecutive days for any emotional distress with no issues noted. The resident’s care plan was reviewed and is in concert with the resident’s current needs and a medical record review completed with no abnormal findings. Unit manager was educated on the requirement to update the resident care plan to accurately reflect interventions. Full house audits will be completed by the nurse managers for all residents with wounds and ensure that the comprehensive individualized care plan for wounds is reviewed and revised to accurately reflect the residents' needs. All unit managers/supervisors educated by the DON/designee to review and revise comprehensive individual care plan weekly or with noted ineffective interventions. Weekly audits will be completed by the unit managers/designee to ensure all residents with wounds have a comprehensive individualized care plan with effective interventions in place. Audits will continue until 100% compliance is attained for 4 consecutive weeks. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported at the monthly QAPI meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.