Failure to Include Surgical Wound Care in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered baseline care plan that included individualized interventions for wound management for one resident. Upon admission, the resident had diagnoses including heart failure, diabetes, and morbid obesity, and was noted to have a surgical wound on the left groin. The admission nursing assessment documented the wound's size and condition, and physician orders specified wound care procedures to be performed twice daily. However, the baseline care plan only addressed the risk for pressure sore development due to mobility deficits and did not include the surgical wound or the physician-ordered wound care interventions. This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan did not reflect person-centered approaches specific to the resident's surgical wound. As a result, the physician-ordered wound care was not incorporated into the resident's care plan within the required timeframe after admission.