Failure to Update Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that the care plan for a resident with a pressure ulcer was updated to accurately reflect the resident's current status and treatment interventions. The resident, who had diagnoses including a sacral pressure ulcer and quadriplegia, was initially care planned for being at risk for pressure ulcers with interventions such as pressure redistribution devices, skin protectants, and daily skin evaluations. The care plan also noted an unstageable pressure ulcer with an intervention for wound clinic services and PICO wound therapy. However, after the PICO therapy was discontinued and the wound progressed to a stage 4 ulcer, the care plan was not updated to reflect these changes. The intervention to use PICO therapy remained in the care plan even though it had been discontinued two months prior, and the care plan continued to list the ulcer as unstageable rather than stage 4. Further, the resident's preferences regarding time out of bed and repositioning, as well as the actual wound care interventions being provided, were not reflected in the care plan. The facility wound nurse confirmed that the care plan was not current and that documentation of turning and repositioning was not included, despite facility policy requiring individualized care plans for residents with pressure ulcers. The policy also required that turning and repositioning be documented in the care plan and that licensed nurses update the care plan as necessary, which was not done in this case.