Failure to Revise Care Plan After Wound Reopened and Enhanced Barrier Precautions Initiated
Penalty
Summary
The facility failed to revise the care plan for a resident after a chronic wound reopened and after the resident was placed on enhanced barrier precautions (EBP). The resident, who had diagnoses including chronic diastolic heart failure, metabolic encephalopathy, and chronic kidney disease, was admitted with moderately impaired cognition and had an activated Power of Attorney for Healthcare. The care plan, dated prior to the wound reopening, did not reflect the presence of the wound or the implementation of EBP. Progress notes documented that the wound reopened and that new physician orders were obtained for wound care, but these changes were not incorporated into the resident's care plan. Staff interviews confirmed that the care plan was not updated to include the reopened wound or the initiation of EBP. The Director of Nursing acknowledged that wound interventions and precautions should have been added to the care plan when the wound reopened. Additionally, the Nursing Home Administrator indicated that the facility did not have a care plan policy in place.