Failure to Develop Person-Centered Comprehensive Wound Care Plan
Penalty
Summary
Surveyors identified a deficiency in the development of a person-centered, comprehensive care plan for a resident receiving wound care. The resident was admitted with diagnoses including cellulitis, ESRD, dependence on renal dialysis, difficulty in walking, and had a terminal prognosis related to lung cancer. The admission MDS showed the resident was at risk for pressure ulcers/injuries and had two Stage 3 pressure ulcers and moisture associated skin damage (MASD) on admission. The care plan, initiated shortly after admission and later revised, documented potential impairment to skin integrity related to multiple comorbidities and noted actual skin breakdown to the right gluteal fold and coccyx. Record review and staff interviews revealed that the care plan was not individualized or person-centered regarding treatment and services for the resident’s two Stage 3 pressure ulcers and MASD. The MDS Coordinator confirmed that the comprehensive care plan, developed from a triggered CAA for pressure ulcers, only addressed risk for pressure ulcers and did not include specific objectives, interventions, or time frames for the actual wounds. The Unit Manager stated she reviewed care plans weekly for specific care needs and appropriate interventions, and the DON was unable to identify appropriate interventions in the care plan for the two Stage 3 wounds or MASD. Review of the facility’s Comprehensive Care Plans policy showed that all triggered CAAs were to be considered in developing the plan of care and that the comprehensive care plan should describe the services to be furnished to attain or maintain the resident’s highest practicable well-being, which was not reflected in this resident’s wound care plan.
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