Failure to Update Care Plan for New Surgical Wound
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to update the care plan for a resident who had recently undergone a surgical amputation of the right toes due to vascular insufficiency and diabetes. Despite physician progress notes and post-operative wound care orders specifying non-weightbearing status, use of a postop shoe, Hoyer lift mobilization, and detailed wound dressing instructions, the resident's care plan did not include any information regarding the surgical procedure, wound care, wound monitoring, or specific mobilization requirements. Observations confirmed the presence of a right foot dressing, and staff interviews indicated that care plans should be updated whenever resident changes occur, but this was not done for the resident in question.