Failure to Care Plan for Resident’s New Skin Discoloration After Change of Condition
Penalty
Summary
The deficiency involved the facility’s failure to develop and implement a person-centered care plan with measurable objectives and timetables after a resident was found with new skin discoloration. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction and was on anticoagulant therapy. The resident’s History and Physical documented that the resident lacked capacity to understand and make decisions, and the MDS showed severely impaired cognitive skills and total dependence on staff for ADLs, bed mobility, and transfers. On 12/1/2025, a certified nursing assistant reported to LVN 3 at 5 AM that the resident had skin discoloration on the left upper arm, left side of the body, and right forearm, and a Change of Condition form was completed that same day. During subsequent interviews and record reviews with LVN 2 and the DON, it was confirmed that there was no care plan addressing the resident’s skin discoloration despite the documented change of condition. LVN 2 stated that LVN 3 should have developed a care plan immediately after identifying the discolorations and completing the COC. The DON also confirmed that no care plan had been created to monitor the resident’s physical and psychosocial condition related to the skin discoloration. This was inconsistent with the facility’s written policy on comprehensive person-centered care plans, which requires development and implementation of care plans with measurable objectives and timetables, and revision of care plans when there is a change in a resident’s condition.
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