Care Plan Lacked Wound Care Interventions for Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident with a pressure ulcer. The resident's electronic medical record showed that the care plan, dated 08/17/23, did not include any wound care interventions, despite physician orders being in place to cleanse and dress open areas on the bilateral buttocks. The care plan only addressed cardiac complications and congestive heart failure, with interventions such as monitoring lung sounds, labored breathing, labs, vital signs, and signs of edema, but omitted any mention of wound care for the pressure ulcer. During the survey, a licensed nurse confirmed that the care plan lacked information regarding wound care for the resident. The resident was observed in her recliner and refused wound care observation. Administrative staff stated that care plans were expected to be completed in a timely manner. The facility's policy requires individualized, person-centered care plans based on the resident's needs, but this was not followed in the case of the resident with a pressure ulcer.