Failure to Develop and Implement Comprehensive Care Plans for Wound Management and Bedrail Use
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to wound care and the use of bedrails. For one resident, multiple wounds were identified upon admission, including a left heel deep tissue injury, a stage 2 sacral pressure injury, a right anterior leg traumatic wound, and a right heel skin fissure, along with skin discoloration on both upper and lower extremities. Despite these findings being documented in the resident's admission records, physician orders, and treatment administration records, there was no corresponding care plan addressing these wounds. The absence of a care plan was confirmed by both the MDS coordinator and the Director of Nursing during record reviews and interviews. Another resident was observed to have bilateral bedrails in use while in bed, a fact confirmed by staff and present since admission. However, there was no care plan in place to address the use of bedrails for this resident. This omission was acknowledged by both the Registered Nursing Supervisor and the Director of Nursing during interviews and record reviews. The facility's policy requires that a comprehensive, person-centered care plan with measurable objectives and timetables be developed and implemented for each resident, based on a thorough assessment and within seven days of the required comprehensive assessment. The lack of care plans for both wound management and bedrail use meant that the residents' specific care needs were not formally addressed or coordinated as required by facility policy. These failures were identified through direct observation, record review, and staff interviews, and were acknowledged by facility leadership.