Failure to Develop Care Plan for Resident's Hand Injury
Penalty
Summary
The facility failed to develop and implement a care plan for a resident who sustained an injury to the right hand, which required sutures. Despite physician orders for daily wound care, including cleansing with normal saline and application of betadine, there was no care plan or documented interventions addressing the care of the sutures. This omission was confirmed during interviews and record reviews with facility staff, who acknowledged the absence of a care plan specific to the resident's hand injury. The resident involved had a history of schizoaffective disorder, depression, and anxiety, with moderately impaired cognition and a need for partial to moderate assistance with activities of daily living. The lack of a care plan was identified through observation, interview, and record review, and staff confirmed that the care plan should have included goals and interventions to maintain suture care and prevent complications. The facility's own policy required a comprehensive, person-centered care plan for each resident, reflecting their needs and physician orders, which was not followed in this case.