Failure to Revise Care Plans for Skin Integrity and GT Management
Penalty
Summary
The facility failed to revise and update care plans for two residents following changes in their conditions and needs. For one resident with a history of self-inflicted scratches and a facility-acquired abrasion to the sacrum, the care plan did not include interventions or treatments to address her self-scratching behavior, despite documentation in the electronic health record and physician's orders for topical treatments and protective measures. Observations and interviews confirmed that staff were aware of the resident's tendency to scratch and the need for regular nail trimming, but these interventions were not reflected in the care plan. For another resident with a gastrostomy tube (GT) and diagnoses including stroke and dementia, the care plan did not include interventions to prevent the resident from pulling out the GT, even though there were multiple documented incidents of the tube being pulled out and specific physician's orders for interventions such as pain assessment, redirection, and one-on-one supervision. Staff acknowledged that these interventions should have been included in the comprehensive care plan but were not at the time of the survey.