Failure to Update Care Plan for New Wounds
Penalty
Summary
A deficiency was identified when the facility failed to update the comprehensive care plan for a resident who developed new wounds. Record review showed that the resident developed abscesses on the bilateral buttocks, as documented in a Skin and Wound Note and a wound assessment. Despite these findings, the resident's care plan was not updated to address the new wounds. The care plan revision history confirmed that no new interventions or goals were added after the wounds were identified. Interviews with facility staff, including a nurse practitioner and the Director of Nursing (DON), confirmed that the wounds were present and that the care plan had not been updated accordingly. The DON acknowledged that the responsibility for updating care plans at the time belonged to a wound treatment nurse, who failed to make the necessary updates. The lack of timely care plan revision was confirmed by both documentation review and staff interviews.