Failure to Update and Implement Comprehensive Care Plan for Resident with Rash and Incontinence Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including COPD, hypertension, dementia, diabetes, and mobility difficulties. Despite the resident being cognitively intact, the care plan was not updated in a timely manner after new orders were received from a nurse practitioner regarding a rash. The care plan did not initially include all prescribed treatments, such as oral doxycycline and fluconazole, and lacked measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Interviews and observations revealed that the resident experienced a persistent rash under the breast and torso, which was associated with incontinence and hygiene challenges. Staff reported that the resident often refused to wear briefs or use the bathroom, resulting in prolonged exposure to moisture and contributing to the skin condition. Multiple staff members, including CNAs, LVNs, and the DON, noted that the care plan was not promptly updated to reflect the new interventions and that this could hinder the delivery of appropriate care. Record reviews and staff interviews confirmed that the care plan was only revised after questions were raised, and prior to that, it did not accurately reflect the resident's current needs or the interventions required. The facility's policy requires ongoing assessment and timely revision of care plans as residents' conditions change, but this was not followed in this case, leading to a gap in care planning and implementation for the resident.