Failure to Develop Timely Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who was admitted with multiple complex medical conditions, including a pressure ulcer. Despite documentation from hospital records and physician notes indicating the presence of a pressure ulcer on the left lateral thigh or buttock at the time of admission, the resident's initial care plan did not address this wound. Instead, the care plan focused on a urinary tract infection (UTI), which, according to staff interviews and the Director of Nursing, had already resolved prior to admission. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for care plan development. The MDS nurse, wound care nurse, and other nursing staff each believed that another team member was responsible for including wound care in the resident's care plan. The wound care nurse stated that interventions for the pressure ulcer were implemented and that education was provided to the resident, but these interventions were not reflected in the baseline care plan. The MDS assessment did document the presence of a pressure ulcer, but this information was not translated into the care plan within the required timeframe. Facility policy required a comprehensive, person-centered care plan to be developed and implemented for each resident, including measurable objectives and timeframes to address identified problems. However, the resident's care plan did not include any mention of the pressure ulcer or related interventions, despite clear evidence from medical records and staff interviews that the wound was present and required ongoing care. This failure to develop and implement an appropriate care plan within 48 hours of admission resulted in a deficiency, as the resident's immediate needs were not formally addressed according to professional standards of care.