Failure to Update Care Plan with Pressure-Relieving Device Intervention
Penalty
Summary
The facility failed to revise the comprehensive care plan (CP) interventions for one resident who was admitted with multiple diagnoses, including a displaced bimalleolar fracture and dementia. The resident was assessed as having moderately impaired cognition and was found to have an unstageable pressure ulcer on the coccyx, with wound care recommendations that included the use of a low-air-loss mattress and turning and positioning measures. Physician orders for an air mattress were documented and initiated, and nursing staff recorded the use of the air mattress in the treatment administration record. However, a review of the resident's comprehensive care plan revealed that there were no interventions or tasks associated with the pressure-relieving air mattress included in the plan. Interviews with nursing staff, including an LPN, unit manager, and clinical nurse, confirmed that the care plan should have been updated to reflect the new physician order for the pressure-relieving device, but this was not done. The facility's policy requires that a comprehensive, person-centered care plan be developed and implemented for each resident, including measurable objectives and timetables to meet their needs. Despite this policy, the care plan was not revised to include the air mattress intervention, as required.