Failure to Revise Care Plans for Skin and Wound Management
Penalty
Summary
The facility failed to revise and update care plans for three residents following changes in their skin and wound conditions, as required by regulation and facility policy. For one resident with a history of failure to thrive and pelvic fracture, the care plan did not include specific interventions for turning, repositioning, or the use of an air mattress, despite a high Braden score indicating risk for pressure injury and subsequent development of a sacral pressure ulcer. The care plan was not updated to reflect the actual wound or prescribed treatments until after the condition worsened, contrary to the facility's own policy on pressure injury management. Another resident, identified as high risk for skin breakdown due to limited mobility, fragile skin, and diabetes, developed a new open wound on the left shoulder. Although an APRN documented the wound and provided treatment orders, there was no evidence that these orders were entered into the medical record, the care plan was updated, or the wound was monitored. The Treatment Administration Record did not reflect the new wound or its treatment, and the Director of Nursing confirmed the care plan was not revised to address the new skin issue. A third resident with cerebral palsy and a significant right hand contracture developed a deep tissue injury on the right index finger. The care plan did not include interventions to prevent pressure injury to the contracted hand, despite clinical notes recommending protective measures such as a finger separator and foam dressing. Observation confirmed the absence of a finger separator and the presence of a dressing, with the resident reporting pain and inability to use the affected hand. The Director of Nursing acknowledged that the care plan did not specifically address the contracture or related pressure prevention.