Failure to Follow Wound Care Recommendations and Update Care Plan
Penalty
Summary
The facility failed to follow the wound care specialist's recommendations for treating a resident's pressure ulcer and did not update the comprehensive care plan to address a new skin alteration. The resident, who was cognitively impaired and dependent on staff for activities of daily living, had multiple hospital admissions and re-admissions. Upon re-admission, a wound care nurse practitioner identified a stage 2 pressure ulcer on the resident's left lateral leg and recommended specific treatment. However, there was no evidence that a treatment order was entered into the electronic health record, nor was there documentation in the Treatment Administration Records (TAR) that the recommended wound care was provided. Interviews with facility staff, including the wound care LPN and the Director of Nursing, revealed that the wound care team may not have been made aware of the resident's wound, and no treatment orders or documentation could be found for the wound in question. Additionally, the resident's care plan was not revised to reflect the new skin alteration, contrary to facility policy, which requires care plans to be updated based on current resident conditions. Facility policies also mandate prompt identification, documentation, and treatment of skin breakdown, as well as timely updates to care plans, but these procedures were not followed in this case.