Failure to Develop Comprehensive Care Plans for Residents with Wounds
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-centered care plans for seven residents who were assessed with various types of wounds, including Stage III and IV pressure ulcers, diabetic foot ulcers, venous ulcers, and arterial ulcers. Specifically, the care plans for these residents did not include goals or interventions related to Enhanced Barrier Precautions (EBP), as required by the facility's own policy and federal regulations. In one case, there was also no evidence of goals or interventions related to a venous ulcer. These deficiencies were identified through observations, clinical record reviews, facility policy review, and staff interviews. The residents affected had significant wounds, such as full-thickness ulcers exposing muscle or tissue, yet their care plans lacked necessary documentation and planning for EBP and, in one instance, for wound-specific care. The facility's policy required the use of the Resident Assessment Process (RAP) for such conditions, but this process was not properly followed for the identified residents.