Failure to Update Care Plan for Noncompliance with Non-Weight Bearing Order
Penalty
Summary
The facility failed to update the care plan for a resident with a diabetic ulcer on the right heel, who was noncompliant with a non-weight bearing order. The resident, admitted with diagnoses including osteomyelitis, type-2 diabetes mellitus, and hypertension, was observed multiple times bearing weight on both legs and walking, despite recommendations from the wound care specialist and education provided by nursing staff. Documentation in the resident's records, including the Non-Pressure Injury Skin Problem Report and Skin/Wound Notes, indicated ongoing noncompliance with the non-weight bearing order. Interviews with the treatment nurse, RN, and DON confirmed that the resident's care plan had not been revised to address the noncompliance, even though the facility's policy required care plans to be updated as residents' conditions changed. The lack of care plan revision meant that interventions to address the resident's noncompliance were not implemented, as acknowledged by the staff involved in the resident's care.