Failure to Revise Wound Care Plan After New Wound Vac Order
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s wound care plan after a new physician order was issued for a wound vacuum-assisted closure (wound vac) to the left hip pressure ulcer. The facility’s policy titled “Care Plan Revisions Upon Status Change,” revised in 2025, requires that the comprehensive care plan be reviewed and revised as necessary when a resident experiences a status change, and that the care plan be updated with new or modified interventions. Record review showed that the resident had an order dated 1/20/26 for a wound vac to the left hip, with instructions to change the dressing every Monday, Wednesday, and Friday on the AM shift and as needed, and to ensure the wound vac dressing was sealed and intact with a setting of 125 mm/Hg every shift every day. However, the corresponding care plan was not updated to include these new wound vac interventions. The resident involved had multiple significant diagnoses, including paralytic syndrome following cerebral infarction affecting the right side, diabetes, COPD, dysphagia, pressure ulcers, chronic kidney disease, hypertension, a rare skin carcinoma, pulmonary embolism, and chronic pain. The most recent MDS indicated a moderate cognitive deficit with a BIMS score of 9/15 and total dependence on staff for all ADLs. During concurrent review of the care plans and interview on 2/5/26, the DON confirmed that the wound care plan needed revision to include specific interventions related to the new wound vac order and acknowledged that the care plan was not revised and needed to be more specific for wound care, including resident-specific considerations such as the resident allowing only one nurse to complete wound care and the potential involvement of a family member if the resident refused treatments. The report states that this failure had the potential for the resident’s wound care not to be managed appropriately, which could result in discomfort, further deterioration of the wound, and possible infection and hospitalization.
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