Failure to Revise Care Plan to Include Physician-Ordered Skin Integrity Intervention
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised to include the use of protective boots as ordered by a physician. The resident, who had multiple diagnoses including Alzheimer's dementia, anemia, diabetes, hypertension, bipolar disorder, impaired cognition, incontinence, psychotropic drug use, and protein calorie malnutrition, was identified as being at risk for impaired skin integrity and pressure injury. Although there was a physician's order for the resident to wear specialized boots to both feet while in bed to maintain skin integrity, this intervention was not added to the resident's care plan during its most recent revision. Additionally, the use of the boots was not documented on the Certified Nurse Aid (CNA) Kardex, which serves as the CNA's plan of care. The Director of Nursing confirmed that the boots were not listed on either the care plan or the CNA Kardex, despite the presence of a physician's order. The expectation, as stated by the DON, was that physician-ordered interventions should be reflected in both the care plan and the CNA Kardex.