Failure to Develop Comprehensive Wound Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing the wound care needs of a resident who was admitted with a dehisced surgical wound on the right knee, following knee surgery. The resident had physician orders for Negative Pressure Wound Therapy (NPWT) three times per week, with specific care instructions. Despite these orders and the presence of an active wound requiring specialized care, the resident's comprehensive care plan did not include any interventions, goals, or timetables related to wound care. This omission was confirmed through observation, record review, and staff interviews. The treatment nurse, responsible for developing wound care plans, acknowledged that no care plan had been created for the resident's knee wound. The DON also confirmed that wound care should have been included in the care plan and was unaware of its absence. Facility policy required the interdisciplinary team to review and update care plans when there is a significant change in a resident's condition, but this was not followed in this case.