Failure to Revise Care Plan After Pressure Injury Worsened
Penalty
Summary
The facility failed to revise the written care plan for a resident after a pressure injury worsened from stage 2 to unstageable. The resident, who was admitted with multiple diagnoses including a left femur fracture, need for assistance with personal care, and cognitive communication deficit, developed a stage 2 pressure injury on the right heel. Documentation showed that the wound progressed to an unstageable pressure injury, but the care plan, which initially noted a right heel blister, was not updated to reflect this change in condition. During a joint interview and record review, the ADON confirmed that the care plan should have been revised when the wound worsened, emphasizing the importance of updating care plans to ensure appropriate care. The facility's policy requires the development of episodic or short-term care plans for acute or temporary changes in a resident's condition, but this was not followed in this case.