Failure to Implement Care Plan Interventions to Prevent Skin Tears
Penalty
Summary
A resident with a history of a syncopal episode resulting in left femur and humerus fractures was admitted to the facility and subsequently developed new skin tears on her left leg. The care plan, initiated after a skin tear incident, included interventions such as keeping nails trimmed, padding wheelchair arms and legs, wearing protective sleeves, using a pressure relief mattress, bunny boots, and exercising caution during transfers. Despite these documented interventions, the resident sustained additional skin tears during transfers, as noted in change of condition records. Observations revealed that the resident did not have protective sleeves on, her nails were long and unkept, and the wheelchair arms and legs were not padded, contrary to the care plan directives. Staff interviews confirmed that these interventions were not implemented as required. The facility's policy stated that the comprehensive care plan should describe the services necessary to maintain the resident's highest practicable well-being, but the specified interventions to prevent further skin tears were not carried out.