Failure to Develop Resident-Specific Care Plan for Wound Protection
Penalty
Summary
The facility failed to develop a resident-specific care plan with measurable interventions for a resident who was non-compliant with care and refused to wear protective foam boots intended to prevent further injury to his feet. The resident was admitted with multiple pre-existing wounds, including chronic wounds on both lower extremities and a necrotic area on the left dorsal foot. Despite documentation of the resident's refusal to wear the prescribed foam boots and the subsequent discontinuation of the order by the physician, there was no evidence that the facility created a care plan to address the refusal or to implement alternative protective measures for the resident's wounds. The care plan did not include interventions tailored to the resident's non-compliance or strategies to ensure wound protection after the boots were refused. As a result of these omissions, the resident's left foot wound developed maggots, which was discovered during routine wound care. The wound was found to have a significant area of dry necrosis with maggots present, necessitating transfer to the hospital for further evaluation and treatment. Staff interviews confirmed that the resident often left his room's sliding door open, potentially allowing flies access to the wound, especially as the wound dressing could become loose or dislodged. The lack of a comprehensive care plan addressing the resident's specific needs and non-compliance directly contributed to the adverse outcome.