Failure to Care Plan for Residents’ Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans addressing pressure ulcers for two cognitively intact residents. Resident #106 was admitted with multiple medical diagnoses, including essential hypertension, paroxysmal atrial fibrillation, chronic obstructive pulmonary disease, and acute kidney failure. The most recent MDS 3.0 assessment showed the resident had an unstageable pressure ulcer upon admission. A progress note dated 02/18/26 documented that this resident had a stage II pressure ulcer, yet review of the resident’s care plan revealed no care plan or interventions addressing the stage II pressure ulcer. Resident #107 was admitted with diagnoses including rheumatoid arthritis, chronic obstructive pulmonary disease, and a cognitive communication deficit, and was also assessed as cognitively intact on the most recent MDS 3.0. A skin evaluation dated 02/05/26 documented a pressure injury to the sacrum that was present upon admission. However, review of this resident’s care plan showed no plan or interventions for a pressure ulcer. During an interview on 03/20/26, the MDS coordinator and the DON confirmed that the care plans did not address the residents’ pressure ulcers or contain related interventions. Facility policy titled “Care Planning,” dated 09/2013, requires that a comprehensive care plan for each resident be developed within seven days of completion of the resident assessment, but this was not done for these residents’ pressure ulcers.
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