Failure to Develop Individualized Care Plans for Pressure Ulcers
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan with measurable objectives, goals, and individualized interventions for a resident with multiple complex medical conditions. During an interview and record review with a registered nurse, it was found that the resident was admitted with diagnoses including paraplegia, chronic kidney disease, multiple contractures, and several stage 4 pressure ulcers at different anatomical sites. The care plan for pressure ulcers grouped all sites together under the same goals and interventions, rather than addressing each ulcer individually. Further review of interdisciplinary team meeting notes revealed that each pressure ulcer had different measurements, treatment changes, and status updates, confirming that individualized care planning was necessary but not implemented. The registered nurse acknowledged that each pressure ulcer site should have been care planned separately to provide person-centered care. The facility did not provide a policy and procedure related to this aspect of care planning.