Failure to Develop Timely Baseline Care Plan for Resident with Skin Integrity Issues
Penalty
Summary
The facility failed to develop a complete baseline care plan within 48 hours of admission for a resident who had a surgical incision and was at risk for pressure injury. Upon admission, the resident had multiple diagnoses including post-surgical orthopedic aftercare, diabetes, heart failure, and chronic kidney disease, and was assessed as having moderately impaired cognition. Medical records and assessments indicated the presence of a surgical incision, moisture-associated skin damage (MASD), and a mild risk for developing pressure injuries. Despite these findings, the baseline care plan did not document the resident's impaired skin integrity, surgical incision, MASD, or include any interventions for treatment and prevention of pressure injuries. Further review showed that the resident's plan of care was not updated to reflect these conditions until the last day of their stay, even though weekly skin assessments and hospital discharge paperwork documented the development of a decubitus ulcer and a stage 3 pressure injury. Staff interviews confirmed that information from the skin section of the MDS assessment should have been incorporated into the care plan, but this was not done in a timely manner. The lack of a comprehensive baseline care plan resulted in the omission of necessary interventions to address the resident's immediate needs related to skin integrity and wound care.