Failure to Develop Care Plans for Residents Requiring Wound Care
Penalty
Summary
The facility failed to develop and implement care plans for two residents who required wound care. One resident had a chronic abscess on the right lateral thigh, returned from the emergency room with new antibiotic orders for cellulitis, and required wound packing to remain in place for 48-72 hours. Despite these needs, there was no evidence of a care plan addressing the wound, including goals and interventions, as of the date reviewed. Another resident had a wound on the left foot and an unstageable pressure ulcer on the right foot, both requiring wound care, but similarly lacked a documented care plan with goals and interventions. These findings were confirmed through record review and interviews with the Director of Nursing and the Director of Clinical Operations.