Failure to Inform and Involve Responsible Party in Pressure Ulcer Care Planning
Penalty
Summary
The facility failed to ensure that the responsible party (RP) for a resident with a stage 4 pressure ulcer was properly informed and included in care planning meetings, as required by facility policy. The resident, who had severe cognitive impairment and lacked decision-making capacity, was admitted with significant medical conditions including a stage 4 sacral pressure ulcer, Type 2 Diabetes Mellitus, and a tracheostomy. Facility policies mandated that the RP be notified of the care plan and participate in the development and revision of the comprehensive care plan, especially for significant conditions such as pressure ulcers. Record reviews and interviews revealed that although the RP was listed as an attendee in care conference documentation, she was not actually present during the meetings. Instead, she was informed separately by phone after the meetings concluded, and the information provided was limited. The RP reported that she was only told that the wound had re-opened, without being informed of the wound's stage, measurements, or specific details. Facility staff confirmed that updates to the RP were not provided regularly or in sufficient detail, and that the RP was not given the opportunity to ask questions or participate meaningfully in the care planning process. Staff interviews further indicated that the RP was not informed about the staging or measurements of the wound, with some staff expressing that such details were withheld because they believed the RP would not understand or would ask more questions. The responsible party was not included in the interdisciplinary care conferences, contrary to facility policy and regulatory requirements, and was not kept fully informed about the resident's wound status or treatment plan. This resulted in the RP being unaware of the severity and progression of the resident's pressure ulcer.