Failure to Develop Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to develop and implement a baseline care plan that addressed the specific care needs of a resident who was admitted with a surgical wound. Upon admission, the resident had a surgical incision on the left lateral thoracic region with three sutures, as documented in the transfer orders from the acute care hospital. These orders included instructions to follow the wound team's recommendations and standard nursing protocols for wound care. Despite these clear instructions, the baseline care plan for the resident did not include a problem or interventions related to the surgical wound. There was no evidence that the facility assessed, monitored, or provided wound care for the surgical incision within 48 hours of admission, as required by regulation. The omission was confirmed during interviews and medical record reviews with the Director of Nursing (DON) and the Administrator, who both verified that the baseline care plan did not address the resident's surgical wound with sutures. As a result, the resident's care needs related to the surgical wound were not met from the time of admission until several months later. This failure was identified through medical record review and staff interviews, and it was determined that the lack of a baseline care plan for the surgical wound had the potential to affect the resident's well-being.
Plan Of Correction
F0655 - Baseline Care Plan Immediate Corrective Action: On 09/02/2025, a treatment care plan was developed for Resident #10 Surgical site. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents with pressure injuries and surgical sites from wound report to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for developing, reviewing, and updating care plans for surgical sites. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting to verify compliance. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025