Failure to Develop and Implement Wound Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with multiple medical conditions, including surgical incisions and a wound vac in use. Medical record review showed that the resident had surgical incisions on both hips and a wound vac applied to the left hip, but the care plan did not include any goals or interventions related to wound care or the use of the wound vac. This omission was confirmed during an interview with the DON, who acknowledged that the care plan lacked the necessary components for wound management for this resident. The deficiency was identified during a review of the resident's medical records and staff interviews, affecting one of three residents reviewed for wound care in a facility with a census of 40.