Failure to Develop and Implement Comprehensive Care Plan for Skin Condition
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with dry skin, despite having a physician's order for daily application of lotion to both upper extremities. The resident, an older male with a history of Vitamin D deficiency, diabetes, and seborrheic keratosis, was observed with flakes of dead skin on his cheeks and reported not liking to take showers. The care plan, last updated months after the lotion order was written, did not address the skin condition or the prescribed treatment. Interviews with staff, including the DON and MDS Coordinator, confirmed that the care plan omission was not identified or corrected, even though the order had been in place for over a month. The DON acknowledged that the resident's skin condition was not care planned and that the facility had sufficient time to include the lotion order in the care plan. The MDS Coordinator stated that standing orders such as the lotion should be care planned and described the process for updating care plans, which involves both the DON and MDS Coordinator. Despite these processes, the care plan for the resident did not reflect the current treatment orders or address the resident's specific skin care needs, as required by facility policy.