Failure to Implement and Develop Care Plans for Wound Care, Repositioning, and Meal Assistance
Penalty
Summary
The facility failed to develop and/or implement complete care plans to meet the needs of several residents, as evidenced by direct observations, record reviews, and staff interviews. Multiple residents with pressure ulcers did not receive the required interventions for turning and repositioning as outlined in their care plans. For example, one resident with multiple pressure ulcers and a Braden Scale score indicating risk was not turned or repositioned every 1-2 hours as required, despite being dependent or requiring substantial assistance for bed mobility. This lack of implementation was confirmed by the Corporate Resource Nurse. Several residents with physician-ordered wound care did not receive treatments as specified in their care plans and treatment administration records. Orders for wound care to various body sites, including heels, elbows, coccyx, and ankles, were not carried out as documented. The care plans for these residents included instructions to provide wound care as ordered, but these interventions were not implemented, as confirmed by staff interviews and record reviews. Additionally, a resident requiring meal assistance and cueing was observed attempting to feed herself without any staff assistance for an extended period, despite her care plan indicating the need for set-up, supervision, and cueing during meals. The resident was unable to effectively feed herself and was not provided the necessary support until a DON intervened. The lack of appropriate meal assistance and cueing was acknowledged by facility leadership. Across all cases, the deficiencies were confirmed by the Corporate Resource Nurse during interviews.