Failure to Update Care Plan After New Skin Condition Identified
Penalty
Summary
The facility failed to update and revise a resident's Comprehensive Interdisciplinary Care Plan (CICP) after the identification of a new skin condition. A resident with diagnoses including dementia, depression, and malignant neoplasm of the breast, and who was dependent on staff for activities of daily living, was found to have a blister on the right buttocks during morning care. The resident was at risk for pressure ulcers and had preventive interventions in place. Documentation showed that the blister was identified, the physician and family were notified, and a treatment order was implemented. However, the CICP continued to reflect only a potential for skin breakdown, not the actual presence of a skin impairment, and did not include the new treatment interventions. Interviews with nursing staff revealed a misunderstanding regarding the need to update the care plan for a blister, with the LPN/Unit Manager stating that a blister was not considered a wound and therefore did not require a care plan update. The Director of Nursing confirmed that the CICP should have been revised to reflect the actual skin impairment and new interventions. Despite the identification and treatment of the new skin issue, the facility did not update the resident's care plan as required by policy.