Failure to Update Care Plan for Skin Integrity After New Wounds Identified
Penalty
Summary
The facility failed to revise and update the care plan for a resident with multiple wounds, resulting in the care plan not accurately reflecting the resident's current skin integrity status. The resident, who has a history of cellulitis in both lower legs, adult failure to thrive, peripheral vascular disease, and local skin infections, was found to have several wounds identified on different dates, including wounds on the right and left dorsal foot, left proximal lower leg, left lower leg anterior, and left buttocks. Despite these new wounds being documented in the electronic medical record, the resident's skin integrity care plan had not been updated since an earlier date, even though four new wounds had been identified since then. During an interview, the wound care nurse confirmed that the care plan should have been updated to reflect the resident's new wounds and acknowledged that this update was missed. The facility's policy requires care plans to be revised to reflect the current status of the resident and to be reviewed throughout the resident's stay, including upon admission, quarterly, and with changes in condition. However, the care plan for this resident was not revised as required, leading to a discrepancy between the resident's documented condition and the care plan.