Failure to Update Care Plan Following Worsening Pressure Injury
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated in response to significant changes in the resident's condition, specifically the worsening of a pressure injury (PI) to the sacrum. The resident was admitted without any pressure injuries and was cognitively intact. Initial assessments and documentation showed no PIs, but subsequent records indicated the development of a Stage 2 PI, which progressed to an unstageable PI and then to a Stage 4 PI with signs of infection, including eschar and slough. Despite these changes, the care plan was not updated in a timely manner to reflect the resident's current status, treatments, or interventions. Interviews and record reviews confirmed that the care plan had not been revised after the initial update, even as the PI worsened. The Wound Care Nurse and the Director of Nursing both acknowledged that the care plan did not reflect the resident's deteriorating condition or the necessary interventions. Facility policy required care plans to be reviewed and revised when there was a significant change in a resident's condition, but this was not followed, resulting in inconsistencies and delays in treatment for the resident's pressure injury.