Failure to Conduct IDT Care Plan Meetings and Update Wound Care Plans
Penalty
Summary
The facility failed to hold and document required care plan meetings with the Interdisciplinary Team (IDT) and the resident or responsible party (RP) within 7 days of quarterly MDS assessments for one resident, and failed to review and revise care plans to address identified skin conditions and new wounds for another resident. For Resident #2, who had diagnoses including COPD, peripheral vascular disease, and multiple pressure-related injuries (sacral pressure ulcer, deep tissue damage of the right heel and another site) and later expired, quarterly MDS assessments were completed on three separate dates. However, there was no evidence in the clinical record that care conferences were held with the resident/RP and the IDT around the time of these assessments. The RP reported not being invited to participate in care plan meetings, the Social Services Director could not find documentation of care conferences or invitations to the RP, and the Administrator, despite stating he believed conferences were held and that attempts had been made to contact the RP, did not provide any supporting documentation by the time of survey exit. The facility also failed to ensure that a resident’s care plan was specific to existing wounds and revised when a new wound developed. For Resident #5, a family member submitted a complaint regarding wound care, and review of wound progress notes showed that on admission the resident had a Stage 3 pressure ulcer to the sacrum, a suprapubic skin tear, and calluses on both heels. The care plan initiated after admission only identified the resident as being at risk for alteration in skin integrity and did not specify or address these ongoing skin conditions. Further review of wound progress notes showed that the resident acquired a new wound on a later date, yet the care plan and its interventions were not revised to reflect this change in condition. During interview, the DON stated that care plans were initiated on admission by the admitting nurse and updated by the Unit Manager or designated staff when there was a change in condition or as needed, and was informed of the failure to include and update the resident’s wound conditions in the care plan.
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