Failure to Implement Care Plan Intervention for Pressure Ulcer
Penalty
Summary
The facility failed to implement a person-centered, comprehensive care plan with measurable goals for a resident with a stage three pressure ulcer. The resident, who had multiple sclerosis, muscle weakness, and moderate cognitive impairment, was dependent on staff for transfers and mobility. Physician orders and the care plan specified the use of a ROHO cushion in the resident's wheelchair to address the risk of skin breakdown and promote healing of pressure ulcers. However, multiple observations and interviews confirmed that the resident was not provided with the required cushion while seated in either his old or new wheelchair. Staff interviews revealed that although the order for the ROHO cushion was present in the electronic medical record, it was not included on the Medication Administration Record or Treatment Administration Record, and nursing staff were not ensuring the intervention was in place. The resident himself confirmed on several occasions that he did not have a cushion in his wheelchair, and this was corroborated by LPNs and the unit manager during direct observation. The Director of Nursing stated that staff were expected to follow care plans and physician orders, but this was not done in this case.