Failure to Implement Care Plan for Dependent Resident with Wound Vac
Penalty
Summary
The facility failed to implement and follow the care plan for a dependent resident who required assistance with activities of daily living (ADLs) and had a negative pressure wound therapy system (wound vac) in place. The resident, who had end stage renal disease on dialysis, decreased mobility, generalized weakness, and severe cognitive deficits, was observed multiple times wearing the same clothes from the previous day, including after returning from medical appointments and while sleeping. Interviews with the resident, complainant, and staff confirmed that the resident was not changed into bed clothes at night, despite having pajamas and gowns available, and that this was not consistent with her preferences or previous habits prior to admission. Additionally, the resident's wound vac, which was ordered to be on continuous suction, was repeatedly found not to be hooked up to suction as required. Observations showed the wound vac tubing attached to the dressing but not connected to suction, and the pump was found unplugged and not in use. Staff interviews confirmed that the wound vac was supposed to be portable and remain on suction at all times, and that failure to do so was not in accordance with physician orders. The wound vac was also not taken with the resident to appointments as required, and alternative dressings were not consistently applied when the wound vac was off. The care plan for the resident included specific interventions for both ADL assistance and wound care, but these were not consistently implemented by staff. The facility's own policy required that care plans be properly developed and implemented, yet staff failed to ensure the resident was changed into appropriate clothing for bed and that the wound vac was maintained as ordered. Multiple staff members, including the DON, RN, and treatment nurse, acknowledged these lapses in care and confirmed that the care plan was not followed.