Failure to Update Care Plan for Altered Skin Integrity
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, resident-centered care plan addressing altered skin integrity for one resident. The resident was noted to have erythema and a rash on the buttocks and thighs, for which antifungal powder was ordered and administered. Subsequent documentation revealed the development of incontinence-associated dermatitis (IAD) and a pressure injury, with additional topical treatments ordered for wound care. Despite these changes in the resident's skin condition and the initiation of new treatments, the care plan was not updated to reflect these developments. The existing care plan only addressed the potential for skin impairment related to immobility and a head laceration, with interventions limited to encouraging range of motion exercises and weight-bearing mobility. No specific interventions were included to address the resident's evolving skin integrity issues, such as the documented pressure ulcer and IAD. Staff interviews confirmed that the care plan was initiated by the admitting nurse and relied on the electronic medical record system to autotrigger updates, but the care plan remained incomplete and was not revised to address the resident's changing needs.