Failure to Develop Baseline Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a baseline care plan related to pressure ulcers for one resident who was admitted with an existing pressure ulcer and subsequently developed additional pressure ulcers. Upon admission, the resident had diagnoses including dehydration, Parkinson's disease, anxiety, and weakness, and was assessed as being at moderate risk for pressure sores according to the Braden Scale. Multiple wound assessments documented the presence of an unstageable decubitus ulcer on the left buttock, a wound on the left iliac crest with purulent drainage and tunneling, and later, a stage I pressure ulcer on the left buttock and a wound on the coccyx. The care plan identified a self-care deficit and potential impairment to skin integrity, but lacked specific instructions regarding pressure-relieving devices, their frequency of use, and did not specify interventions for all identified wounds. Interviews and document reviews revealed that the baseline care plan was not properly developed or implemented. The DON acknowledged that the initial care plan was created with assessments, but indicated that nurses did not complete the necessary steps to link interventions to the care plan. The facility's policy required individualized, person-centered care plans to address identified problems and needs, but this was not followed in the resident's case, resulting in incomplete documentation and lack of clear, actionable interventions for pressure ulcer management.