Incomplete Comprehensive Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents following their admission, as identified through observations, record reviews, and interviews. One resident was admitted with multiple stage 4 pressure ulcers and was at risk for developing additional pressure injuries. The care plan for this resident did not specify the type and location of the pressure ulcers, despite documentation in the Minimum Data Set (MDS) and the resident's own report of pressure ulcers on her right heel and bottom. Another resident, admitted with a stage 2 pressure ulcer and at risk for further skin breakdown, also had a care plan lacking details on the type and location of the pressure ulcer. Additionally, the care plan for this resident did not include interventions to prevent new pressure ulcers from developing. Staff interviews revealed that CNAs and LPNs relied on care plans for guidance on pressure ulcer care, including repositioning and maintaining skin integrity. However, the care plans reviewed did not provide individualized or comprehensive interventions, and staff reported not having access to care sheets. The MDS Coordinator and Assistant Director of Nursing confirmed that care plans should include specific information about the presence, monitoring, and treatment of pressure ulcers, as well as preventive measures, but these elements were missing or incomplete in the reviewed care plans. Further review indicated that the facility lacked a clear policy regarding the development and updating of comprehensive care plans, as the current management could not locate relevant policies from previous ownership or provide new ones. This lack of policy guidance contributed to the incomplete documentation and planning for residents with pressure ulcers, as evidenced by the care plans and staff statements.