Jeri Lundgren

We have a strong wound care team that rounds together weekly. However, we just received a citation due to our care plans not reflecting the care we are providing. How do I ensure this doesn’t happen again?

When I perform care plan audits, I often find the facility is doing more interventions than they are capturing on the plan of care. Weekly wound rounds should not be limited to just the assessment of the wound — but the plan of care. 

Ensure all the risk factors, goals and interventions listed on the plan of care are current and capture the care you are providing. Doing so will also allow you to update the care plan with any changes identified during wound rounds. Once the care plan is updated, ensure the nursing assistant assignment sheets are also current, reflecting the interventions they are to implement. Initially, it may take you longer to perform wound rounds. However, as you get into a routine, you will be more proficient and ensure your care plans are up to date. 

It is also important to note and address any barriers to providing appropriate care or any medical condition that is hindering healing. Ensure there is an interdisciplinary approach to the review, including but not limited to input from the nursing assistants, floor nurses, dietary, therapy and the practitioner. 

Once the team gets used to reviewing and updating the care plan with weekly wound rounds, I recommend taking a preventive approach by reviewing all your residents. A schedule could be made to review a certain number of residents’ skin integrity care plans each week, so that over every quarter, all the skin integrity care plans are examined. 

When looking at the plan of care from a preventive standpoint, ensure the resident’s risk factors are being properly addressed with appropriate interventions to minimize the risk of developing a pressure injury or skin breakdown.