Failure to Develop and Implement Care Plan for Pressure Injury
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan to address a new pressure injury for a resident with multiple medical conditions, including dementia, chronic kidney disease, anemia, and a recent right humerus fracture. The resident was admitted with a right arm immobilizer following a fall and subsequently developed a stage 3 pressure injury on the right wrist, as documented in the medical record and confirmed by an orthopedic consult. Although treatment orders for the pressure injury were obtained, there was no evidence in the medical record that a care plan with specific interventions, treatment goals, and outcomes was created or implemented to address the wound care needs. Facility policy requires individualized care plans based on comprehensive assessments and mandates updates to care plans following significant changes in a resident's condition. Despite these requirements, interviews with facility staff, including the Unit Manager and DON, confirmed that the care plan was not updated to reflect the new pressure injury. The lack of documentation and failure to amend the care plan after the development of the pressure injury constituted a deficiency in meeting the resident's wound care needs.