Failure to Document Surgical Wound and Interventions in Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan that included all necessary information for providing care to a newly admitted resident with a surgical wound. Specifically, a resident admitted with a diagnosis of a left femur fracture and a surgical incision with staples did not have this wound or the required wound care interventions documented in their baseline care plan. Physician orders were in place for wound care, including cleaning the incision and ensuring a dressing was in place each shift until staple removal, but these interventions were not reflected in the baseline care plan. Interviews confirmed that staff were performing wound care and that the resident was scheduled for staple removal, yet the baseline care plan omitted any mention of the surgical wound or related interventions. The Director of Nursing acknowledged that staff were expected to document all wounds and interventions in baseline care plans, but this was not done for the resident in question.