Care Plan Not Updated for Non-Pressure Wound
Penalty
Summary
The facility failed to revise the care plan to include a non-pressure wound for a resident who had moderate cognitive impairment and required extensive assistance with activities of daily living. The resident had multiple diagnoses, including chronic respiratory failure, congestive heart failure, heart disease, osteoarthritis, anemia, hypertension, and Alzheimer's disease. Although the care plan addressed the potential for skin alterations due to immobility and incontinence, it did not identify or include interventions for a non-pressure wound on the resident's right foot second toe, which was identified by staff. The director of nursing confirmed that care plans were expected to be updated with any change in resident status or new skin concerns, and facility policy required care plans to be current at all times.