Failure to Update Care Plan for Pressure Ulcer Prevention and Management
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan addressing skin care and pressure ulcer prevention for a resident who developed a Stage 2 pressure ulcer. The resident, who had diagnoses including type 2 diabetes mellitus, seborrheic dermatitis, schizoaffective disorder, and COPD, was assessed as being at low risk for pressure ulcer development using the Braden Scale and had a pressure-reducing device for his bed. Despite these risk factors and the presence of a formal assessment indicating potential for altered skin integrity, the care plan did not include a specific area for skin care or pressure ulcer prevention, nor was it updated after the development of the pressure ulcer. The resident's medical record documented the emergence of two open areas on the right upper buttock, which were first observed and treated by staff, and subsequently confirmed as a Stage 2 pressure ulcer. Physician orders were obtained for wound care, including cleansing, application of wound gel with collagen, and use of a foam dressing, as well as nutritional supplementation to support wound healing. The wound and the resident's condition were communicated to the physician, family, and dietitian, and interventions such as a pressure-relieving cushion and hygiene education were provided. However, these interventions were not reflected in the resident's care plan, and staff interviews confirmed that the care plan lacked necessary updates and interventions related to skin care and wound prevention. Facility policy required the development of a comprehensive, individualized care plan to address pressure ulcer prevention and management, including collaboration among the resident, representative, physician, dietitian, and clinical staff. The failure to update the care plan with appropriate interventions after the development of the pressure ulcer constituted a deficiency, as it did not meet the facility's own standards or regulatory requirements for care planning and risk management.