Failure to Update Care Plan and Implement Pressure Injury Interventions
Penalty
Summary
The facility failed to update or revise the comprehensive care plan for a resident with multiple pressure injuries, including a Stage 2 flank wound and a Stage 3 coccyx wound, which were not identified in the admission assessment. Weekly skin assessments later documented these wounds, but the care plan did not reflect goals or interventions for their management. There was also no documentation of communication regarding the new pressure injuries in the dialysis communication binder, and staff interviews revealed inconsistent understanding and implementation of repositioning and offloading protocols. The resident, who was cognitively impaired and dependent on staff for care, was observed without appropriate offloading devices and was not repositioned as needed, despite being at high risk for pressure injuries. Further observations and interviews indicated that staff, including CNAs and therapy personnel, believed that repositioning was unnecessary if an offloading cushion was used, and there was no scheduled turning program in place. The DON and Risk Manager confirmed the absence of a formal turn and reposition policy, and the wound care team had not reported significant changes in the resident's wound status, such as the presence of black tissue. The resident's physician and physician's assistant were not aware of the wound's progression, as they relied on nursing staff for updates, which were not provided. Photographic evidence was obtained to support these findings.