Failure to Address Pressure Ulcer Risk from Assistive Devices in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan addressing all of a resident's needs, specifically for a resident with severe cognitive impairment, no speech, highly impaired hearing, and impaired vision. The resident was completely dependent on staff for all activities of daily living and had multiple diagnoses, including acute and chronic respiratory failure with hypoxia, tracheostomy, and anxiety disorder. Assessments identified the resident as being at risk for pressure ulcers, and the care plan noted the resident's consistent use of eyeglasses and headphones for a pocket talker device, which she often refused to remove, even during sleep. Despite these findings, the care plan did not include interventions to prevent skin breakdown or pressure ulcers related to the continuous use of eyeglasses and headphones. Interviews with nursing staff and the DON confirmed that the care plan lacked specific prevention interventions for pressure ulcers on the nose or ears, areas at risk due to the resident's refusal to remove her devices. The facility's care planning policy requires the interdisciplinary team to develop individualized care plans based on comprehensive assessments, but in this case, the care plan was not updated to address the identified risks associated with the resident's use of assistive devices. This omission resulted in a failure to meet the resident's needs for pressure ulcer prevention as required by facility policy.