Failure to Develop and Implement Comprehensive Care Plans for Wound and Fracture
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan for a resident who developed a wound on the coccyx and sustained a fractured left clavicle. Despite facility policy requiring care plans to include objectives, timetables, and measurable outcomes, there was no documentation of a care plan addressing the resident's new open area and Moisture-Associated Skin Damage (MASD) to the coccyx. The wound was identified through skin assessments and nurse progress notes, and a wound nurse practitioner provided treatment recommendations. However, nursing did not document the wound location in the care plan or update it with interventions, treatment goals, and outcomes as required. Additionally, after the resident sustained a left clavicle fracture and was discharged from the hospital with instructions for sling use and monitoring, there was no care plan developed to address the fracture, use of the sling, non-weight bearing status, or monitoring for complications such as numbness. The medical record lacked documentation of interventions, treatment goals, or outcomes related to the fracture and associated care needs during the relevant period. Interviews with nursing staff and the DON revealed confusion regarding responsibility for care plan development and updates. The DON stated that both staff nurses and the MDS nurse were responsible for initial care plans, with the MDS nurse updating them as needed. However, the expected comprehensive care plans addressing the resident's wound and fracture were not developed or implemented, contrary to facility policy and expectations.