Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan for a resident with multiple pressure ulcers. The resident was admitted with several stage 4 and unstageable pressure ulcers, as well as other significant medical conditions including a urinary tract infection and a gastrostomy tube. The resident was assessed as having severely impaired cognitive skills and was totally dependent on staff for daily care activities. Despite these complex needs, only a baseline care plan was created upon admission, and no comprehensive care plan was developed more than two months after admission. Interviews with facility staff confirmed the absence of a comprehensive care plan. The Clinical Manager acknowledged that while a baseline care plan was in place, there was no comprehensive care plan addressing the resident's multiple pressure ulcers. The Clinical Manager emphasized the importance of such a plan for guiding the monitoring and treatment of the wounds, noting that without it, there was no specific guidance for wound care. The Director of Nursing also confirmed that the baseline care plan is only valid for 14 days and that a comprehensive care plan should have been developed by the interdisciplinary team within that timeframe. A review of the facility's policy and procedure on comprehensive care plans indicated that care plans should be created for skin alterations, including pressure ulcers, and that goals should be realistic, measurable, and include a timeframe for re-evaluation. The failure to develop a comprehensive care plan for the resident's pressure ulcers was contrary to both regulatory requirements and the facility's own policy, resulting in a lack of documented, coordinated interventions for the resident's wound care needs.
Plan Of Correction
F -656 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.