Failure to Document Progressive Interventions on Care Plan After Skin Injuries
Penalty
Summary
The facility failed to ensure that progressive interventions were documented on a resident's care plan following multiple incidents of skin tears and bruising. One resident with multiple diagnoses, including dementia, chronic pain, malnutrition, and frail skin, experienced several skin injuries during transfers and while using a wheelchair. Although interventions such as leg and arm sleeves were implemented after specific incidents, these were not consistently or promptly documented in the resident's care plan. For example, after a skin tear to the right forearm, the use of arm sleeves was not documented, and leg sleeves were not added to the care plan until months after the initial injury. Additionally, no intervention was documented to prevent further bruising to the resident's arms following a significant bruise incident. Interviews with staff revealed inconsistencies in the process for updating care plans with new interventions. The Care Plan Coordinator stated that interventions are typically documented the same day or the next business day, but on weekends, nurses are expected to start interventions immediately and notify the coordinator for later documentation. The Director of Nursing expected nurses to add interventions to care plans during the same shift as the incident. However, the facility's care planning policy did not specify a timeframe for documenting progressive interventions, contributing to the lack of timely updates to the resident's care plan.