Failure to Develop and Implement Comprehensive Care Plan for Resident with Wound and Non-Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a stroke, poor circulation, and nicotine dependence. The resident was moderately cognitively impaired, totally dependent on staff for activities of daily living, and at risk for pressure ulcers. Despite developing an arterial wound on her left outer ankle, the care plan did not address the wound or the resident's non-compliance with care instructions. Assessments showed the wound worsened over time, and documentation from the wound physician linked poor healing to the resident's smoking and failure to offload pressure. Interviews with staff revealed ongoing challenges in managing the resident's care, including her preference to remain in bed, resistance to repositioning, and repeated removal of positioning aids. Staff and family attempted to encourage mobility and offloading of pressure, but the resident remained largely non-compliant, expressing disbelief in the education provided. The care plan was not updated to reflect these issues, and the Assistant Director of Nursing acknowledged being behind on care plan updates due to being new in the role.