Failure to Update and Develop Comprehensive Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop and update comprehensive care plans for two residents with pressure ulcers. For one resident, a provider note documented a new open area on the sacrum, but no new treatment orders were written, and the care plan for skin had not been updated since a previous date. Interviews with staff confirmed that the new wound was not addressed in the care plan and that treatments had not been completed as required. The medication administration record also did not reflect any new orders for the newly identified wound area. For another resident, progress notes indicated the development of multiple pressure ulcers, including an unstageable area, a stage 2 ulcer, and a deep tissue injury. Observation confirmed the presence of these wounds, but the care plan, which was initiated earlier, had not been updated to include interventions for the new pressure areas. Staff interviews confirmed the absence of care plan interventions for the pressure ulcers that developed subsequently.