Failure to Revise Care Plan After Resolution of Pressure Ulcer
Penalty
Summary
The facility failed to review and revise the care plan for a resident with a history of hemiplegia, hemiparesis, muscle weakness, and moderate protein-calorie malnutrition following a stroke. The resident developed a Stage 3 pressure ulcer, which was present from early July to mid-August. Despite the resolution of the pressure ulcer, the care plan continued to list an active focus on altered skin integrity related to limited mobility and an open area to the coccyx, with no updates or revisions made after the ulcer healed. A quarterly MDS assessment completed at the end of August indicated that the resident no longer had any pressure ulcers. However, the care plan was not updated to reflect this change, as confirmed by the DON during an interview. Facility policy requires care plans to be reviewed and updated at least quarterly or when there is a significant change in the resident's condition, but this was not done in this case.