Failure to Update Care Plan with Accurate Interventions for Skin Integrity
Penalty
Summary
Facility staff failed to review and revise the interdisciplinary care plan to accurately reflect interventions for a resident with significant medical needs. The resident, admitted with diagnoses including cardiac arrest resulting in anoxic brain damage, asthma, and ventilator dependence, developed a deep tissue injury (DTI) to the left heel, as documented in weekly skin assessments from late December through January. Additional wounds, including a Stage 2 pressure ulcer to the left ischium and a DTI to the right buttock, were also noted during this period. Despite these findings, the care plan created for the resident only included general interventions for skin integrity, such as incontinence checks, use of barrier cream, daily skin inspections, and weekly wound monitoring. The care plan was not updated to include specific interventions for the resident's heels, such as elevation or floating of heels, use of heel boots, application of skin prep to heels, or provision of an air mattress. The Director of Nursing confirmed during an interview that the care plan should have been updated to reflect these interventions.