Failure to Revise Care Plan to Include Bed Cradle Intervention
Penalty
Summary
The facility failed to revise the care plan for one resident to include the use of a bed cradle, an intervention implemented to prevent pressure on the resident's feet. The resident, who had diagnoses including Parkinsonism, diabetes mellitus type II, dementia, and joint contractures, was assessed as having impaired cognition and being dependent on staff for all activities of daily living. The resident was also identified as being at risk for pressure ulcers. Upon admission, the wound care nurse noted boggy heels with redness, and later, redness was observed on the great toes. The wound care nurse documented that treatment included skin prep and the use of a bed cradle. Despite these interventions being implemented, a review of the resident's care plan revealed that the use of the bed cradle was not included as an intervention to prevent pressure on the resident's feet. Observations confirmed the bed cradle was in use, but the care plan had not been updated to reflect this. Interviews with the wound care nurse and the MDS Coordinator confirmed that the omission occurred and that only the MDS Coordinator was authorized to revise care plans.