Failure to Implement Care Plan for Pressure Injuries
Penalty
Summary
Facility staff failed to implement the care plan for a resident with pressure injuries, as evidenced by delays in carrying out wound care treatments and interventions as ordered by the wound nurse practitioner. The resident was admitted with existing skin impairments, including a Stage 2 sacral pressure injury and deep tissue injuries (DTIs) on both heels. The care plan and treatment recommendations included specific wound care regimens, use of an air mattress, and heel-floating interventions. However, documentation review showed that these treatments were not initiated in a timely manner. For example, wound care orders for the sacrum and right heel were not implemented until several days after being recommended, and the air mattress was not provided until even later. Similarly, a new wound on the left heel was not treated according to recommendations until over a week after the order was given. Interviews with facility staff, including a unit manager and administrative staff, confirmed that all staff are responsible for implementing care plan elements, which are designed to address the resident's diagnoses and needs. Despite this, the care plan interventions for the resident's pressure injuries were not followed as ordered. Additionally, a review of the facility's care planning policy revealed no information emphasizing the importance of adhering to the care plan, further highlighting the lack of implementation for this resident's wound care needs.