Failure to Include Wound Vac Therapy in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that included measurable objectives and time frames to address the use of wound vacs for two residents. Both residents had documented medical needs for wound vac therapy as part of their treatment for lower extremity wounds, as indicated by physician orders and medical records. However, review of their care plans revealed that the use of wound vacs was not included, despite being a significant aspect of their care. For one resident, records showed a recent toe amputation and the presence of a wound vac to the distal lower leg, with physician orders specifying that the wound vac should not be removed or changed until seen by a surgeon. The care plan initiated upon admission did not address the wound vac, even though the resident was cognitively intact and required this specific intervention. Similarly, another resident with a history of chronic conditions and a diabetic foot ulcer had physician orders for wound vac therapy, but the care plan failed to include this treatment. Interviews with nursing staff, the DON, and the administrator confirmed that wound vac therapy should have been included in the care plans as it is essential for individualized care and communication among staff. Staff acknowledged that the omission could lead to miscommunication and that it was the responsibility of various team members to ensure care plans were accurate and up to date. Review of the facility's care plan policy also indicated that baseline care plans should be developed upon admission and updated as needed, but this was not followed in these cases.