Failure to Develop Care Plan for Resident's Hematoma
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address a right eye hematoma for a resident. The resident, who had a history of type 2 diabetes mellitus, required assistance with personal care and had moderate cognitive impairment. The hematoma was first observed by staff, who documented its presence and questioned the resident about its origin, but the resident was unsure how it occurred. Despite this, there was no care plan created to address the hematoma, as confirmed by a review of the resident's records and an interview with the Director of Nursing (DON). The DON acknowledged that the care plan for the hematoma was missing and should have been developed when the wound was first noted. The facility's policy requires the interdisciplinary team to create a comprehensive care plan with measurable objectives and timeframes for each resident's needs, but this was not followed in this case. The absence of a care plan for the hematoma was confirmed through observation, interviews, and record review.