F0656

D

Failure to Develop Comprehensive Care Plan for Resident With Stage IV Pressure Ulcers

Catonsville, Maryland Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

Facility staff failed to develop a comprehensive, person-centered care plan for a resident admitted with extensive Stage IV pressure ulcers. The resident was admitted with paraplegia due to a motor vehicle accident, Stage IV pressure ulcers to the left buttock, sacral region, and left ankle, a local infection of the skin and subcutaneous tissue, and unspecified severe protein-calorie malnutrition. A pressure ulcer care plan was created and initiated with a goal that the resident would be free from signs of infection and that the ulcers would improve by the next review date. The listed interventions included carefully drying between toes without applying lotion between them, positioning the resident off affected areas, changing position every two hours and as needed, and a general directive for wound/dressing care "as order" with instructions to observe and change dressings and record observations at a frequency to be specified.

The care plan was not comprehensive or resident-centered for the type and severity of the resident’s pressure ulcers. It did not specify the types of wound dressings or the frequency of dressing changes and observations. The plan omitted interventions to prevent further worsening of heel ulcers, such as elevating the heels or using heel boots. It also failed to include any information about the ordered wound vac, including monitoring for an intact seal, assessing for infection, bleeding, or fluid leakage. Additionally, the care plan did not address the type of mattress the resident should use. During review of the pressure ulcer care plan with the DON, the DON acknowledged that the care plan was not comprehensive for the resident’s pressure wounds present on admission.