Failure to Update Care Plans Following New Wounds and Pressure Injuries
Penalty
Summary
Facility staff failed to revise and update care plans for three residents after the development of new wounds or pressure injuries. For one resident, the care plan was not updated to reflect a newly identified pressure injury on the left heel, despite clinical documentation and treatment recommendations by the wound nurse practitioner. The care plan only referenced prior skin impairments and did not include the new wound, as confirmed by both the regional director of clinical operations and the unit manager during interviews. Another resident developed a stage 3 pressure ulcer on the left buttock, as documented in the skin and wound progress notes. The care plan for this resident did not include the presence of the stage 3 pressure ulcer or any interventions to address it, even though the wound nurse practitioner had provided specific treatment recommendations. Staff interviews confirmed that the care plan should have been updated to include all current wounds and interventions. A third resident developed an abrasion on the left gluteal fold that required treatment. The care plan was not updated to reflect the presence of this wound, despite clinical documentation and treatment recommendations. Staff interviews consistently indicated that care plans are intended to map out all aspects of resident care, including wounds, and that all nurses have the ability to update care plans as needed. The facility's policy requires care plans to be updated on an ongoing basis as changes occur, but this was not followed in these cases.