Failure to Revise Care Plan After Development of Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident who developed a pressure ulcer after admission. The resident, who had a history of cerebral vascular accident and diabetes mellitus, was admitted without pressure ulcers and was assessed as having severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The initial care plan identified the resident as being at risk for impaired skin integrity and included interventions such as frequent turning, skin monitoring, and prompt notification of nursing staff for any open areas. However, when an unstageable wound with black eschar and foul odor was discovered on the resident's right heel, the care plan was not updated to reflect this new development. Medical records showed that the wound nurse documented the new pressure ulcer and obtained treatment orders, including antibiotics, an X-ray, and a wound consult. Despite this, there was no evidence that the care plan was revised to address the new pressure ulcer. Interviews with the MDS nurse revealed that she was informed of the new wound during a clinical meeting but failed to update the care plan upon returning to her office. The administrator confirmed that it was the MDS nurse's responsibility to revise care plans promptly for new developments such as pressure ulcers.