Failure to Develop and Implement Comprehensive Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address all of a resident's needs, specifically regarding the management and prevention of pressure ulcers. The resident, who was dependent on a wheelchair and had diagnoses including vascular dementia and diabetes, was observed multiple times without a seating cushion in the wheelchair and without linens on the bed. The medical record indicated the development of two facility-acquired stage II pressure ulcers in the intergluteal region and posterior scrotum. Recommendations from a nurse practitioner for a low air loss mattress and a pressure-relieving wheelchair cushion were documented, but these interventions were not observed in use during multiple observations. The care plan for the resident did not reflect the presence of pressure ulcers or include interventions for pressure relief, despite the documented wounds and recommendations. The MDS assessment did not include cognition and mood assessments, and the MDS nurse was unaware of the pressure ulcers, acknowledging that their development should have triggered a significant change assessment and a corresponding care plan. Existing care plans referenced impaired skin integrity but did not specify the pressure ulcers or detail appropriate interventions for pressure relief.
Plan Of Correction
F656 – Develop/Implement Comprehensive Care Plan Element #1: The facility updated the care plan for R11 to reflect current clinical status and interventions. Element #2: A review was initiated by the Director of Nursing and/or designee of all new admissions in the past 30 days to ensure comprehensive care plans were developed and implemented within the required timeframe, and are an accurate reflection of the resident's status. Element #3: The Administrator reviewed the policy on Comprehensive Care Plans and revised as necessary. Education on the policy was provided to Licensed Nurses and Department Managers to ensure Care Plans are up to date and accurate to reflect the resident's status. Element #4: The Director of Nursing and/or designee will review 5 residents weekly for 12 weeks to confirm accuracy and timeliness of care plans and interventions. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025