Failure to Develop Comprehensive Care Plan for Foot Infection
Penalty
Summary
Surveyors found that the facility failed to ensure a resident-centered, comprehensive care plan was written to address an identified foot infection and open foot lesion. CMS SOM Appendix PP requires each resident to have a person-centered comprehensive care plan that addresses medical, physical, mental, and psychosocial needs, and the facility’s RAI & Comprehensive Care Plans policy requires the IDT to develop such a plan within 7 days of completing the comprehensive assessment. Resident #1, who had multiple diagnoses including chronic kidney disease, peripheral venous insufficiency, and morbid obesity, had a Quarterly MDS assessment documenting an infection of the foot and another open lesion on the foot. Despite this, the resident’s electronic medical record did not contain documentation indicating treatment for wounds, and the care plan initiated and later revised did not include any directions for care of the foot wound or infection. During interview, the MDS nurse confirmed that the resident did not have a care plan for the foot infection and acknowledged that there should have been one. This deficient practice was cited for 1 of 3 residents whose care plans were reviewed and was noted by surveyors as creating the risk of adverse outcomes if comprehensive care plans did not reflect the necessary care for each resident.
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