Failure to Develop and Implement Individualized Care Plans for Device and Wound Management
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two residents, resulting in deficiencies related to the management of complex medical devices and wound care. For one resident with a history of gallbladder cancer, bile duct obstruction, and recent hospitalizations, the facility did not create a care plan addressing the presence and maintenance of biliary drains and a portacath, despite clear documentation in the hospital discharge summary and active physician orders for device care. Interviews with staff revealed a lack of awareness regarding the need for a care plan for these devices, and the Director of Nursing confirmed that such devices should have been included in the resident's care plan. Another resident, admitted with dementia and a history of falls, had an unhealed heel pressure ulcer that was not reflected in the current care plan. The care plan only documented previously resolved pressure ulcers on the elbow and buttock, omitting the current heel ulcer. Staff interviews confirmed that the care plan was outdated and did not accurately reflect the resident's current skin condition, as required by facility policy and standard care practices. These deficiencies were identified through document review, observation, and staff interviews, which demonstrated that the facility did not ensure care plans were updated and individualized to address residents' current medical needs, including specialized device care and wound management. The lack of comprehensive, timely, and accurate care planning failed to meet the facility's own policies and regulatory requirements.