Failure to Update and Personalize Wound Care Plans
Penalty
Summary
The facility failed to ensure that care plan interventions for a resident with multiple complex medical conditions were personalized, implemented, and updated to reflect changes in wound management. The resident had a history of hemiplegia and hemiparesis following a stroke, type 2 diabetes mellitus with neuropathy, Parkinson's disease, encephalopathy, and dysphagia. The initial care plan identified risks for altered skin integrity and included general interventions such as skin assessments, weekly skin checks, and the use of off-loading devices. However, as the resident developed new and worsening wounds, including a full-thickness dermatosis and unstageable pressure ulcers, the care plan was not promptly or adequately updated to address these changes. Physician orders and wound assessments documented the progression of the resident's wounds, including the development of a new full-thickness dermatosis, an unstageable pressure ulcer on the coccyx, and a deep tissue injury (DTI) on the right heel. Orders for specific wound care treatments, such as the application of Triad cream, medical grade honey, and the use of a low air loss mattress, were issued as the resident's condition changed. Despite these changes, the care plan did not consistently reflect the updated interventions or the evolving clinical picture. Documentation also revealed that some wounds were not identified or documented in a timely manner, and there was a lack of detailed information regarding the acquisition, description, and management of certain wounds. Interviews with facility staff indicated that the responsibility for updating care plans in response to new or worsening wounds was not clearly defined or consistently executed. Audits conducted by facility management revealed that a significant proportion of residents with wounds required care plan updates, and that some skin issues were undocumented. The facility's policies required individualized care plans, communication of risk factors and interventions, and ongoing evaluation and modification of care plans, but these practices were not consistently followed for the resident in question.