Failure to Develop Individualized Care Plan for Wound Dressing Removal Behavior
Penalty
Summary
A deficiency was identified when the facility failed to develop a comprehensive, individualized care plan addressing a resident's behavior of removing their own wound dressings. The resident, who had a history of surgical aftercare, Type II diabetes mellitus, peripheral vascular disease, and a chronic non-pressure ulcer on the right ankle, was assessed as having severely impaired cognitive skills and required moderate to maximal assistance with activities of daily living. Despite these needs and the resident's behavior of removing wound dressings due to itchiness, there was no care plan in place to address this specific behavior. Interviews with facility staff confirmed that the behavior was known, as the resident would often be found with dressings removed, and staff acknowledged that a care plan should have been developed to address this issue. The Director of Nursing stated that the absence of a care plan for this behavior could put the resident at risk, and that such incidents should have been documented and communicated to the physician. Review of facility policies confirmed the requirement for comprehensive, person-centered care plans with measurable objectives and timeframes for each resident.