Failure to Timely Assess and Update Care Plan for Pressure Injuries
Penalty
Summary
The facility failed to timely and accurately assess a resident for pressure injuries and did not update the care plan after the identification of bilateral heel deep tissue injuries. The resident, who had impaired cognition and was non-ambulatory, was admitted with significant medical diagnoses including metabolic encephalopathy and fractures. Upon admission from the hospital, the resident had right and left heel deep tissue injuries, which were treated with skin prep and foam dressing. However, the use of heel protectors was not included as a physician order or as an intervention in the care plan. The Braden assessment inaccurately documented the resident's mobility status, conflicting with the Minimum Data Set (MDS) and care plan, which indicated the resident was dependent and non-ambulatory. Weekly skin assessments conducted by the facility repeatedly documented no loss of skin integrity, even after the hospital and facility records confirmed the presence of bilateral heel pressure injuries. One assessment was recorded while the resident was not present in the facility, and subsequent assessments failed to note the existing injuries. The facility's policy required that actual pressure injuries be addressed in the care plan and that assessments be timely and accurate, but these steps were not followed for this resident.