Failure to Care Plan Newly Identified Sacral Skin Breakdown
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames for a newly identified excoriated area on the sacrum of one resident. Facility policy titled “Care Plan Process,” revised 12/24, requires that care plans include measurable objectives, time frames, and descriptions of services to attain or maintain each resident’s highest practicable well-being, and that care plans be reviewed and revised on an ongoing basis. Record review of the Care Plan Report for Resident #1 showed no care plan addressing the excoriated sacral area, despite Progress Notes dated 2/15/26 documenting the presence of a new excoriated area to the sacrum requiring treatment and monitoring. The resident’s face sheet indicated admission on 5/22/2019 with diagnoses including Diabetes Mellitus and Cerebral Infarction. In interviews, an RN stated that the purpose of the care plan was to ensure staff knew how to care for the resident, and the MDS Nurse confirmed that no care plan had been developed for the new skin breakdown and acknowledged that one should have been implemented. This deficiency reflects the facility’s failure to follow its own care plan policy and to create a care plan for the resident’s newly identified sacral skin breakdown, despite documented need for treatment and monitoring and staff acknowledgment of the care plan’s role in guiding resident care.
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