Failure to Monitor and Update Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper monitoring and care planning for pressure injuries in two residents. One resident was readmitted with no documented skin impairment but was later found to have redness and discoloration on both great toes, likely related to compression socks. Despite this finding, there were no further assessments or measurements of the affected areas, and the care plan was not updated to reflect the new skin condition. Staff interviews revealed that the areas were not reassessed after the initial finding, and the DNS was not notified of the skin changes, contrary to facility protocol. Another resident was admitted with intact skin but developed a facility-acquired Stage 2 pressure wound to the sacrum and buttocks shortly after admission. The wound was not identified until several days after admission, and the initial wound assessment was inaccurate. The care plan was not revised to address the new wounds, and no incident report was completed as required by facility policy. The DNS acknowledged these lapses, including the failure to notify the physician, initiate an investigation, and document the wound accurately.