Failure to Include Pressure Ulcer and Wound Care in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for one of three residents reviewed. Specifically, a resident was admitted with a documented stage 2 pressure ulcer on the sacrum, as noted in physician orders and progress notes. The physician orders included specific wound care instructions, and the admission MDS indicated the presence of a pressure ulcer and the need for pressure ulcer care. However, the baseline care plan created for the resident did not document the existence of the pressure ulcer or the need for wound care. During interviews, the resident's family member reported that there was no plan of care in place, and the DON confirmed that the baseline care plan did not include the pressure ulcer or wound care needs. The deficiency was identified through record review and interviews, which showed that the required information for immediate care was not included in the baseline care plan as expected.