Failure to Develop and Implement Comprehensive Care Plan for Resident with Wound and Pacemaker
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including a stage three sacral pressure wound and a pacemaker. The care plan did not address the resident's sacral wound or other skin integrity issues, despite the presence of a physician's order for daily wound care and recommendations for pressure-relieving interventions. Additionally, the care plan section for the pacemaker was incomplete, lacking specific information such as manufacturer, model, serial number, date of implantation, and cardiologist details. Record reviews revealed that wound care was not documented as provided on several weekend dates, and the resident reported not receiving wound care on weekends, as well as a general lack of care during those times. The resident also noted the removal of a low air loss mattress, which was recommended for pressure relief, after it became nonfunctional, and it was not replaced. Interviews with staff indicated that care planning responsibilities were not consistently followed, with confusion over which staff members were responsible for updating care plans for wounds and medical devices. Facility policies required comprehensive care plans with measurable objectives and timeframes to address each resident's needs, including physical, psychosocial, and functional aspects. However, the care plan for this resident did not reflect these requirements, as it omitted critical interventions and failed to ensure continuity and documentation of care, particularly for wound management and pacemaker monitoring.