Failure to Develop and Implement Comprehensive Care Plans for Pressure Ulcer and Diet Change
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to both pressure ulcer management and dietary changes. For one resident with type 2 diabetes, generalized muscle weakness, reduced mobility, and moderately impaired cognition, the facility did not create a care plan addressing a stage II pressure ulcer on the sacrococcyx, despite physician orders for daily wound care. The Minimum Data Set Coordinator confirmed that no care plan was in place for the pressure ulcer or its treatment, and the Director of Nursing acknowledged that this omission could result in the resident not receiving proper care. Another resident, admitted with diffuse traumatic brain injury, gastrostomy, and tracheostomy, experienced a significant change in diet order from a twice-daily pureed diet to three daily meals of regular mechanical soft texture. Staff interviews revealed that both a Certified Nursing Assistant and a Registered Nurse were unaware of the new diet order, and the care plan had not been updated to reflect the change. The Director of Nursing confirmed that care plans should be revised as residents' conditions change, but this was not done in this case. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan within specified timeframes, including measurable objectives and timeframes, and to revise care plans as residents' conditions change. In both cases, the lack of updated care plans meant that staff were not properly guided in providing necessary care and services for the residents' current needs.