Failure to Revise Care Plans as Residents' Conditions Changed
Penalty
Summary
The facility failed to ensure that care plans were revised as residents' care needs changed for two out of four residents reviewed. One resident was admitted with a stage III sacral pressure ulcer and subsequently developed additional pressure wounds, including unstageable and stage II ulcers on the right inner thigh and gluteal folds, as well as pressure ulcers on the left great toe and heel. Despite documented worsening of the sacral pressure ulcer over several weeks, with increasing wound size and depth, the care plan interventions remained unchanged from those implemented at admission. No new interventions were added to address the progression of the wound, and the care plan was not updated to reflect the resident's changing condition. Another resident, who did not have pressure ulcers upon admission, sustained a fall resulting in an abrasion on the back, which later developed into a stage III pressure ulcer. Although a care plan was in place identifying risk for skin breakdown, the interventions were not updated to reflect the actual development of a stage III pressure ulcer. The care plan was not revised with new interventions until a significant delay after the wound had progressed. Staff interviews confirmed that care plans should have been updated with new interventions as the residents' conditions changed, but this was not done in these cases.