Failure to Revise Care Plans for Infection Control and Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised in a timely manner for three residents, resulting in deficiencies related to infection control and pressure ulcer prevention. For one resident with a history of vancomycin-resistant enterococcus (VRE) in the urine, the care plan was not updated to reflect the discontinuation of contact isolation and the implementation of enhanced barrier precautions (EBP) as ordered by the physician. Both the Infection Preventionist and the Director of Nursing confirmed that the care plan should have been revised to indicate the current precaution status, but it was not, which could create confusion among staff regarding the appropriate infection control measures. Two other residents, both at high risk for developing pressure ulcers, had physician orders for the use of low air loss mattresses (LALM) to preserve skin integrity. However, their care plans were not updated to include the LALM as an intervention for pressure ulcer prevention. Observations revealed that the LALM settings for both residents did not match their current weights, as required by manufacturer specifications and facility policy. Nursing staff acknowledged that the care plans should have been revised to reflect the use of LALM and that the settings should be adjusted according to the residents' weights to prevent skin breakdown. The facility's policy requires that care plans be developed and implemented within seven days of the comprehensive assessment and be reviewed and updated when there are changes in the resident's condition or interventions. Despite this, the care plans for these residents were not revised to reflect current orders and interventions, leading to potential miscommunication among staff and a delay in necessary care and services. The deficiencies were identified through record reviews, staff interviews, and direct observations.