Failure to Develop Accurate Baseline Wound and Nutritional Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a baseline care plan within 48 hours of admission that accurately reflected a resident’s identified conditions and physician orders. Policy and procedure required a baseline care plan within 48 hours that included minimum health care information and interventions for special needs such as wound care and dietary orders. The resident was admitted with severe cognitive impairment and an initial skin assessment documented 10 pressure injuries and wounds, including pressure injuries to the sacrococcygeal area, hips, gluteal fold, heel, side of the right foot, a surgical incision with separated wound edges, a skin tear on the right arm, and open wounds on the right knee and left ear. Despite these findings, review of the baseline care plan initiated shortly after admission showed no care plan addressing pressure injuries or wounds. During interviews, the IP, an LVN, and the DON each confirmed that no wound care plan had been developed for any of the resident’s wounds, and all stated that each wound should have its own care plan with specific interventions and goals, and that the absence of such a plan could compromise or jeopardize the resident’s plan of care. The facility also failed to create an accurate baseline nutritional care plan consistent with the resident’s NPO status and enteral feeding orders. Physician orders documented that the resident was NPO and receiving enteral tube feedings, and a swallowing evaluation noted loss of liquids/solids from the mouth, residual food after meals, and coughing or choking during meals or when swallowing medications. A physician progress note further documented that the resident was nonverbal, NPO, and fed via GT. However, the nutritional care plan developed for the resident included interventions such as honoring food preferences, offering substitutes if less than 50% of the meal was eaten, and allowing ample time to eat and drink, which implied oral intake. In an interview, the DON confirmed that the nutritional care plan did not reflect the physician’s NPO and enteral feeding orders and acknowledged that the care plan was incorrect and could have led staff to believe the resident was able to take food or water by mouth, with a stated risk of aspiration into the lungs if oral intake occurred.
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.