Failure to Develop Care Plan for Resident’s Genital Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a care plan to address a documented change in condition for one resident who developed erythema and moisture-associated maceration of the scrotal and penile area. The resident had been admitted with diagnoses including nontraumatic intracerebral hemorrhage, acute respiratory failure, quadriplegia, and type 2 diabetes, and was identified on the MDS as having severe cognitive impairment, being rarely or never understood by others, and being dependent on staff for oral hygiene, toileting hygiene, showering, and dressing. The MDS also indicated the resident was at risk for developing pressure injuries. On a specified date, a Change of Condition (COC) note documented redness and moisture-associated maceration to the resident’s scrotal area and penis. During interview, the LVN who assessed the resident’s skin and created the COC acknowledged that she did not create a corresponding care plan to reflect the resident’s skin changes. She stated that failing to develop a care plan for the skin changes could cause a delay in the resident receiving timely assessments and consistent treatments. The DON stated that the resident was at risk for skin breakdown and that all COCs must be followed up with an appropriate care plan to address goals and interventions, and described the care plan as a tool used to communicate the resident’s plan of care to staff to ensure consistent care. Review of the facility’s policy on comprehensive person-centered care plans indicated that the IDT is to review and update the care plan when there has been a significant change in the resident’s condition, but this was not done for the documented skin condition.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.