Failure to Update Care Plan After Resident Skin Tear
Penalty
Summary
The facility failed to develop and implement a resident-specific care plan following a change in condition involving a skin tear to the left shin. The resident, who had a history of cellulitis of the right lower limb, chronic respiratory failure, and lack of coordination, sustained a skin tear during a transfer from a shower chair to a wheelchair. Immediate treatment was provided, including cleansing, application of steri strips, and a dry dressing, and a physician's order was obtained for ongoing wound care and skin maintenance. Despite these interventions, there was no documented evidence that the care plan was updated to reflect the new skin tear. The treatment nurse confirmed that the care plan was not revised to include the new condition, and acknowledged the importance of updating care plans after such changes. The Director of Nursing also stated that care plans should be updated after any change in condition to ensure all staff are aware of the necessary interventions. The facility's policy requires care plans to be modified as needed to reflect changes in status, but this was not followed in this instance.