Failure to Update Care Plan for Pressure Ulcer and Prescribed Interventions
Penalty
Summary
The facility failed to update the care plan for a resident who developed a pressure ulcer while residing in the facility. Observation revealed the resident was awake, alert, and sitting up in bed with some confusion, and had a dime-sized, shallow, crater-like open area on the coccyx covered with dried white cream. The CNA reported the pressure ulcer had developed a couple of weeks prior and that a cream was being applied. The RN confirmed the pressure ulcer was facility-acquired and, upon review of the electronic health record, could not find documentation of a care plan addressing the pressure ulcer. The most recent care plan for skin integrity, last reviewed months earlier, only included a goal for the skin to remain free from breakdown and did not reflect the current skin impairment or prescribed interventions. Progress notes from the Wound Care Practitioner documented the presence of moisture-associated skin damage and a small open area at the coccyx, with specific recommendations for wound care, pressure relief, and dietary interventions. These recommendations included the use of zinc oxide cream, a dry bulky dressing, aggressive off-loading, a foam wedge, a low-air-loss mattress, off-loading heel boots, and a dietitian consult. However, these interventions were not incorporated into the resident's care plan. The Director of Nursing acknowledged that the orders and recommendations were missed and the care plan was not updated, contrary to the facility's policy requiring the interdisciplinary team to develop a relevant care plan after assessment.