Failure to Initiate Baseline Skin Breakdown Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a baseline care plan for skin breakdown within 48 hours of admission for one resident. According to the facility's policy, the interdisciplinary team is required to create a care plan with measurable goals for the prevention and management of pressure injuries after a thorough assessment. The resident in question was admitted with multiple diagnoses, including a right hip fracture, severe dementia, depression, muscle weakness, and mobility abnormalities. The admission assessment documented a dressing on the right hip, bruising on both antecubital areas, and redness under both breasts, indicating a risk for skin breakdown. The resident's skin assessment showed a score of 9, signifying a very high risk for skin breakdown, and triggered the need for a skin/wound care plan. However, the medical record revealed that the first skin/pressure/vascular ulcer care plan was not initiated until four days after the required 48-hour window. The Director of Nursing confirmed that the baseline care plan was not developed within the expected timeframe.