Failure to Update Care Plan for Pressure Ulcer Progression
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed, updated, and revised for one resident with significant skin integrity issues. Specifically, the resident, who had severe cognitive impairment, hemiparesis, and was dependent for all care, developed a Stage 2 pressure ulcer to the sacrum and bilateral buttocks while in the facility, in addition to a Stage 4 pressure ulcer present on admission. The care plan in place only addressed a Stage 4 pressure ulcer on the left heel and did not include documentation of the sacral/buttocks ulcer, its measurements, treatments ordered, or updates on wound progression and physician findings, despite these being reported to the facility. Interviews with nursing leadership revealed that wound care physician notes were received weekly, and it was the expectation that nursing staff would update the care plan with any changes in wound status or treatment orders. However, the care plan was not updated to reflect the presence or progression of the sacral/buttocks ulcer, nor were physician findings consistently documented. The responsibility for updating care plans was described as belonging to unit managers, but this was not carried out as required by facility policy and regulatory standards.