Failure to Update Care Plan After Change in Pressure Ulcer Status
Penalty
Summary
The facility failed to update and revise the comprehensive care plan for a resident with a pressure ulcer after a significant change in the wound's condition and treatment. The resident, who had multiple diagnoses including hemiplegia, hemiparesis, acute posthemorrhagic anemia, and generalized muscle weakness, was admitted with an unstageable pressure ulcer on the right buttock. Following a wound assessment and debridement, the pressure ulcer was reclassified as a stage 4 wound, and new treatment orders were initiated. However, the care plan continued to reflect the previous unstageable status and did not incorporate the updated stage or new treatment interventions. Interviews with nursing staff, a nurse practitioner, and the assistant director of nursing confirmed that the care plan was not updated to reflect the current wound stage and treatment orders. Staff acknowledged the importance of timely care plan updates for accurate communication and guidance in wound care. Review of facility policies and job descriptions indicated that care plans should be revised to reflect changes in residents' conditions and treatments, but this was not done in this case.