Failure to Update Care Plan for Resident with Lymphedema and Skin Integrity Issues
Penalty
Summary
The facility failed to revise and update the care plan to accurately reflect the current status and care needs of a resident with multiple medical conditions. Upon review, it was found that the resident had diagnoses including traumatic spinal cord dysfunction, anemia, neurogenic bladder, and lymphedema with frail skin. The resident sustained a laceration to the right anterior medial shin when staff were assisting with dressing, which was attributed to the hook from a urine bag catching the leg. Documentation indicated the wound was significant, with a v-shaped skin flap, visible fatty tissue, and serosanguinous drainage, and the resident's skin was described as shiny, fragile, and edematous. Despite these findings and the resident's history of lymphedema and skin integrity issues, the current care plan did not include any interventions for lymphedema or preventative measures for impaired skin integrity. Interviews with staff, including a nurse aide and a registered nurse, confirmed that the care plan lacked these necessary interventions. The Nursing Home Administrator also acknowledged that the care plan had not been revised to reflect the resident's current needs, resulting in a deficiency under the cited regulations.