Incomplete Care Plan for Resident with Active Skin Issues
Penalty
Summary
Facility staff failed to maintain a complete and accurate care plan for a resident who was readmitted with multiple diagnoses, including heart failure, diabetes mellitus, non-Alzheimer's dementia, altered mental status, adult failure to thrive, and abnormal weight loss. Upon readmission, the resident was documented as having a right trochanter blister and a scabbed area on the coccyx, with a history of pressure ulcers and being at risk for further ulcer development. However, the care plan did not address these active skin issues or specify expected interventions for their management. Clinical documentation showed that the initial assessment upon readmission noted the presence of skin issues but did not provide further assessment details such as measurements, condition of surrounding skin, drainage, or odor. The facility's own Skin Quick Reference Guide required a head-to-toe assessment, documentation, and initiation of care plan interventions, but these steps were not completed as required. The care plan remained incomplete and failed to reflect the resident's current needs related to skin integrity.