Failure to Include Wound Treatment Order in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a healing surgical wound on the left hip. The resident had diagnoses including acute osteomyelitis of the left femur, infection and inflammatory reaction due to an internal left hip prosthesis, and dysphagia. Upon review, it was found that the resident required surgical wound care and was dependent on staff for several activities of daily living. Despite these needs, the care plan did not include a treatment order for the left hip wound until nearly two months after admission. Interviews with nursing staff confirmed that a treatment order for the surgical wound was not obtained at the time of admission, and the care plan initially failed to address this critical intervention. The facility's policy required that care plans include measurable objectives and timetables to meet each resident's needs, and that all residents with wounds have a wound treatment order included in their care plan. The omission of the wound treatment order in the care plan was identified during record review and staff interviews.