Failure to Develop and Implement Comprehensive Care Plan for Pressure Injury Prevention
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically regarding the prevention of pressure injuries for a resident identified as high risk. Upon admission, the resident had multiple diagnoses, including a wedge compression fracture and end-stage renal disease, and was assessed as cognitively intact but totally dependent on staff for mobility and hygiene. The resident was determined to be at high risk for pressure injuries based on a Braden Scale score of 11 and had no pressure injuries upon admission. Despite the resident's high risk status and total dependence on staff for repositioning and hygiene, documentation revealed repeated refusals by the resident to turn, reposition, and participate in hygiene care over an extended period. Staff documented these refusals and provided education on the risks and benefits of compliance, but the care plan was not updated to address the resident's ongoing refusals or to outline specific interventions for managing these refusals. The facility's policy required care plans to include measurable objectives and interventions, including those related to resident refusals, but this was not done in this case. As a result of the lack of a comprehensive care plan addressing the resident's refusals and high risk for pressure injuries, the resident developed an unstageable pressure injury to the coccyx and a deep tissue injury to the right heel, both acquired in-house. Interviews with staff and review of documentation confirmed that the care plan did not reflect the resident's pattern of refusal or provide guidance for staff on how to address these refusals, contributing to the development of the pressure injuries.