Failure to Include Pressure and Surgical Wounds in Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that included pressure and surgical wounds for two residents receiving wound care. For one resident, an older female with diagnoses including a right femur fracture, dementia, muscle weakness, and a pressure ulcer of the left lower back, the admission MDS documented one unhealed stage 2 pressure ulcer present on admission. However, the resident’s most recent comprehensive care plan did not include any focus, goals, or interventions related to pressure or surgical wounds. Additionally, the discharge return anticipated MDS later incorrectly documented that the unhealed stage 2 pressure ulcer was not present upon admission or reentry during the look-back period. During a joint interview, the MDS nurse who completed the admission MDS recalled a decision to address pressure wounds in the care plan but was unable to locate such a care plan in the record, and the DON confirmed she was not aware the wounds were missing from the comprehensive care plan. For another resident, an older female with metabolic encephalopathy, type 2 diabetes mellitus, malnutrition, anemia, dementia, and bilateral knee contractures, a recurrent stage 3 sacral pressure ulcer was diagnosed by the wound care PA, and the quarterly MDS documented an unhealed pressure ulcer not present on admission or reentry during the look-back period. Physician’s orders for sacral wound care treatment were implemented and documented on the Treatment Administration Record. Despite this, review of the current comprehensive care plan showed no focus for the resident’s pressure ulcer. In a joint interview, the DON and Nursing Home Administrator acknowledged that the pressure ulcer care plan for this resident had been missing from the comprehensive care plan. The facility’s own standards and guidelines required comprehensive person-centered care plans with measurable objectives and timeframes to meet residents’ medical and nursing needs identified in the comprehensive assessment, which were not followed in these cases.
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.