Failure to Update Care Plan After Skin Breakdown and Changing Risk Status
Penalty
Summary
The facility failed to ensure a resident’s care plans were updated to reflect changes in condition and new clinical findings. The resident had severely impaired cognitive skills and diagnoses including non-Alzheimer’s dementia and depression, and was incontinent, non-ambulatory, and dependent on staff for ADLs. A quarterly MDS documented these conditions, and the facility’s incident tracking log showed an alleged incident of neglect involving this resident on 12/27/25. The resident’s care plan initiated on 12/5/23 addressed mixed bladder incontinence with goals related to maintaining dignity and remaining free from skin breakdown due to incontinence and brief use, and this care plan was last revised on 11/19/24. Another care plan initiated on 3/4/24 identified the resident as at risk for impaired skin integrity, but there were no further updates to this care plan. Subsequent clinical documentation showed clear changes in the resident’s skin condition that were not incorporated into the care plans. A progress note dated 11/15/25 described the coccyx area as showing signs of breakdown, starting to open and red, with barrier cream and a silicone border Mepilex dressing applied and skin treatment orders initiated in the TAR. A progress note dated 11/18/25 documented a Braden score of 13 with detailed risk factors, including very moist skin, chairfast activity level, very limited ability to change position, adequate nutrition, and friction and shear problems. Another progress note dated 12/3/25 recorded an opening on the sacral area and application of a new Mepilex dressing. Despite these documented changes and the facility policy requiring comprehensive care plans to be reviewed and revised by the interdisciplinary team at least after each comprehensive and quarterly MDS assessment, the DON confirmed that the resident’s care plans had not been updated.
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