Failure to Document Wound Care Interventions in Care Plan
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to develop an accurate, person-centered comprehensive care plan for a resident admitted with a left fibula fracture and surgical wounds on the left knee and ankle. Record review showed that while physician orders and the MDS assessment documented the presence of surgical wounds and required wound care, the resident's care plan did not include the specific interventions ordered to treat these wounds. During an interview, the DON confirmed that although the care plan noted the existence of wounds, it lacked documentation of the interventions in place to promote healing, despite staff expectations to include all such interventions in the care plan.