Failure to Develop Baseline Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop a baseline care plan with appropriate interventions to prevent pressure injury or trauma for a resident diagnosed with diabetes and other significant health conditions. Upon admission, the resident was assessed as cognitively impaired, with fluctuating inattention and disorganized thinking, bilateral lower extremity impairment, wheelchair dependence, incontinence, and substantial assistance required for hygiene and bed mobility. The resident's diagnoses included a progressive neurological condition, hypertension, diabetes mellitus, cerebrovascular accident, dementia, malnutrition, Parkinson's disease, and a psychotic disorder. The resident had experienced significant recent weight loss and was identified as being at risk for developing pressure ulcers, as indicated by the Braden assessment and clinical evaluation. Despite these findings, the clinical record did not contain a care plan addressing the resident's risk for pressure ulcers or interventions to prevent skin breakdown, particularly in light of the resident's uncontrolled diabetes, decreased bed mobility, and substantial weight loss. Although the MDS assessment indicated that skin and ulcer treatments were in place, such as pressure-reducing devices for the chair and bed, there was no evidence of a turning/repositioning program or application of dressings to the feet at the time of admission. The absence of a baseline care plan within the first 48 hours of admission was not in accordance with the facility's policy and regulatory requirements.