Failure to Implement Comprehensive Care Plan and Daily Body Checks
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident by not performing daily body checks as required by the resident's care plan and the facility's own policies. The resident had a history of mild intellectual disabilities, limited mobility, and was at risk for developing pressure ulcers, as documented in the care plan and Minimum Data Set (MDS). The care plan specifically included interventions such as daily body checks for redness and open areas, keeping the skin clean and dry, and protecting the skin from moisture. Despite these documented needs and interventions, staff did not consistently perform or document daily body checks. A Licensed Vocational Nurse (LVN) assigned to the resident noticed a foul odor but did not conduct a full body assessment, stating it was outside their scope of practice. The LVN reported the odor to a Registered Nurse (RN), but the only action taken was to provide another shower, even though the odor persisted. The Director of Nursing (DON) confirmed that the facility's policy required full body skin assessments by licensed or registered nurses, particularly for residents at risk of pressure ulcers, and that this protocol was not followed in this case. As a result of the failure to follow the care plan and perform required skin assessments, the resident developed an infected wound on the left wrist, which was later identified at an acute care hospital as an embedded rubber band causing infection. The lack of adherence to the care plan and facility policy directly contributed to the development and delayed identification of the wound.
Plan Of Correction
F 656 Develop/Implement Comprehensive Care Plan CFR(s): 483.21(b)(1)(3) Resident 1 was re-admitted back to our facility on 3/28/25. He was assessed by the RN supervisor on 3/28/25. Left wrist noted with dry scab with no signs of infection. Care plan reviewed and revised by the RN supervisor on 3/28/25. DON, RN/LVN supervisors performed body/skin checks to the current residents on census as of 4/10/25 to identify any resident affected with the findings. Body/skin checks were completed on 4/30/25. No other residents were affected. DON in-serviced licensed nurses regarding Comprehensive Care Plan Implementation on 4/9, 4/11, and 4/28. At least quarterly, every 10th, DON will in-service regarding Comprehensive Care Plan Implementation. Weekly, during IDT care plan meetings, MDS nurse, RN/LVN supervisors assigned, and Social Services designee will review the care plan of residents on schedule to ensure that body/skin assessment was performed as written in the care plan. Findings will be corrected and will be reported to the DON for follow-up. Any significant findings will be reported by the DON during the quarterly QA&A meetings for discussion and recommendation for 6 months.