Failure to Develop Comprehensive Care Plan for Resident with Colostomy and Wound
Penalty
Summary
Facility staff failed to develop and implement a comprehensive care plan for a resident with significant medical needs, including a colostomy, an open abdominal wound, and requirements for assistance with activities of daily living (ADLs). The only care plan in place addressed fall risk, with interventions limited to therapy referrals. No care plan interventions were documented for the resident’s colostomy care, wound management, or ADL support, despite these needs being clearly identified in the resident’s Minimum Data Set (MDS) and through direct observation. Observations revealed that the resident had a colostomy bag with feces present and an open abdominal wound with thick, yellow drainage, both of which were not addressed in the care plan. The resident reported that their abdominal bandage needed changing, and staff confirmed that care plans should include such interventions. Multiple staff interviews indicated that care plan meetings had ceased several months prior due to the former DON’s refusal to participate, resulting in care plans not being updated or developed for residents with new or ongoing needs. Staff, including the Social Service Director, LPN, and CMT, acknowledged that care plans were incomplete and not reflective of residents’ current care requirements. The Administrator and Senior Director of Regulatory Affairs confirmed that care plan meetings were not being held and that there was no clinical staff available to participate in the process. As a result, the resident’s care needs for colostomy management, wound care, and ADL assistance were not addressed in the care planning process.