Failure to Develop Timely Baseline Care Plan for Pressure Injury
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with a left medial heel deep tissue injury. Documentation review showed that the resident had diagnoses of muscle weakness, malnutrition, and depression, and was identified as being at risk for pressure ulcers with an unhealed pressure injury present at admission. Despite facility policy requiring a baseline care plan to address immediate health and safety needs within 48 hours, there was no evidence that such a plan was created to address the resident's pressure injury until four days after admission. The care plan for the left heel deep tissue injury was not developed and implemented until after the required timeframe.