Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple pressure ulcers, despite the resident's complex medical history and high level of dependency. Upon admission, the resident was diagnosed with several stage 4 and unstageable pressure ulcers, a urinary tract infection, and had a gastrostomy tube in place. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily care activities. Although a baseline care plan was created at admission, no comprehensive care plan was developed more than two months later to address the resident's pressure ulcers. Interviews with facility staff confirmed that the comprehensive care plan, which should have been developed by the interdisciplinary team within 14 days of admission, was not completed. The Clinical Manager acknowledged the absence of a comprehensive care plan for the resident's wounds, and the Director of Nursing confirmed that the baseline care plan was only valid for 14 days. Facility policy required comprehensive care plans for skin alterations and pressure ulcers, with realistic, measurable goals and time frames for re-evaluation, but this was not followed in the resident's case.