Failure to Update Care Plan and Implement Pressure Ulcer Prevention After Change in Condition
Penalty
Summary
The facility failed to update the care plan for a resident following a significant change in condition after hospital readmission, resulting in the development of three pressure ulcers. The resident, who had multiple medical diagnoses including rib and vertebral fractures, prostate cancer, and diabetes, was initially assessed as not at risk for pressure ulcers. However, after a hospitalization for deep vein thrombosis and pneumonia, the resident became bedbound, experienced cognitive decline, and required substantial assistance with mobility and activities of daily living. Despite these changes, the care plan was not revised to include specific interventions for pressure ulcer prevention after the resident's readmission. The only interventions listed were general measures such as gentle handling, observation of skin during ADLs, and weekly skin assessments. No new interventions were added after the resident developed a sacral pressure ulcer, a right heel pressure ulcer, and a left hip pressure ulcer. Additionally, no further Braden Scale assessments were completed after the change in condition, and there was no documentation system in place for staff to record repositioning. Observations confirmed that the resident was consistently found lying on his back in bed with heels not elevated, despite the use of a low air loss mattress. Interviews with nursing staff revealed that the resident required frequent repositioning and heel elevation, but these interventions were not reflected in the care plan or documented in the medical record. The lack of care plan updates and documentation contributed to the failure to implement appropriate pressure ulcer prevention measures.