Failure to Include Wound Care Interventions in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a recent surgical wound. Despite physician orders specifying wound care instructions—such as allowing a PICO dressing to remain for one week, then removing it and notifying the physician with a photo of the underlying wound—these interventions were not incorporated into the resident's care plan. Record reviews confirmed that the care plan lacked focus, goals, and interventions related to wound care, even though the resident was at risk for pressure ulcers and required assistance with walking. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The MDS Coordinator, ADON, and Wound Care Nurse each believed that others were responsible for ensuring wound care was included in the care plan. The Wound Care Nurse admitted to providing wound care without updating the care plan, citing oversight. The MDS Coordinator stated he could not update the care plan without information from the Wound Care Nurse, and the ADON acknowledged that the care plan should have been revised to reflect the wound care being provided. The facility's policy required baseline care plans to include initial goals based on admission orders and to be updated with necessary healthcare information. However, the lack of communication and clear assignment of responsibility resulted in the omission of wound care interventions from the resident's care plan. This failure was identified by the DON and Administrator, who confirmed that the care plan had not been updated to include the resident's wound care needs.