Failure to Develop and Implement Care Plan for Deep Tissue Injury
Penalty
Summary
The facility failed to develop and implement a care plan addressing a deep tissue injury (DTI) for a resident admitted for short-term rehabilitation following a pelvic fracture. Upon admission, the resident was found to have a DTI on the sacrum, as documented in the skin assessment, and was identified as being at risk for skin breakdown based on a Braden Scale score. The resident reported decreased mobility and pain with movement and repositioning, and stated that nursing staff applied a cream to the affected area daily. Despite these findings, a review of the resident's care plans revealed no interventions or strategies in place to address the DTI, prevent further skin breakdown, or promote healing. During interviews, the facility's wound nurse confirmed the presence of the DTI and described interventions such as a foam dressing, specialty bed, cushion, and frequent repositioning, noting that staff assistance was needed to prevent shearing. However, these interventions were not documented in the resident's care plan. The lack of a documented care plan meant that there were no measurable actions or timetables established to address the resident's skin integrity needs, resulting in a deficiency related to the development and implementation of a comprehensive care plan.