Failure to Develop Care Plan for Skin Tear Prevention
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a care plan to address the prevention of skin tear injuries for a resident with multiple risk factors. The resident was admitted with diagnoses including a laceration to the left forearm, muscle weakness, lack of coordination, vision problems, and vascular dementia. The resident was also prescribed Plavix, a medication that increases the risk of bleeding. Despite these risk factors, the facility's records showed multiple incidents of skin tear injuries over several months. Review of the resident's care plan revealed no documented interventions or strategies to prevent further skin tear injuries. Interviews with facility staff confirmed that no care plan addressing these risks was developed or implemented, and no explanation was provided for this omission. The lack of a care plan occurred despite repeated incidents and the resident's ongoing vulnerability to injury.