Failure to Update Care Plan for New Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by policy and regulatory standards. Specifically, the care plan was not updated to include a left heel wound that was identified by a physician order. The resident, an older adult male with chronic kidney disease stage 3, heart failure, and pneumonia, had severe cognitive impairment as indicated by a BIMS score of 06. Despite the physician's order to apply xeroform and a bordered gauze dressing to the left heel, the care plan dated after the wound was identified did not reflect this new condition or the required interventions. Interviews with facility staff, including the Administrator, Wound Care Nurse, MDS Coordinator, and DON, confirmed that it was their responsibility to update care plans to reflect changes in residents' conditions. Staff acknowledged the importance of including all resident needs in the care plan to ensure appropriate and consistent care. The facility's own policy required ongoing assessment and timely revision of care plans as residents' conditions changed, but this was not followed in the case of the resident with the left heel wound.