Failure to Assess and Document Wounds Upon Admission
Penalty
Summary
The facility failed to provide care and services that met professional standards for a resident with stage three chronic kidney disease and anxiety disorder. Upon admission from the hospital, the resident's discharge records did not indicate any wounds. However, a Licensed Practical Nurse (LPN) documented multiple wounds on the resident's feet and chest, but marked 'None of the above were present' in the admission document for ulcers, wounds, and skin problems. The LPN also marked 'No Referrals Necessary' for wound care, and did not provide further information on the wound characteristics or type. A Registered Nurse did not assess the wounds upon admission, and there was no documentation to the physician about the wounds. The physician's assessment the following day did not note any lesions, indicating a lack of communication. The facility's wound nurse did not assess the resident's foot until two days after admission, and initially reported scabs rather than wounds. However, a subsequent observation revealed a wound with eschar on the resident's toe, which was later diagnosed as a full thickness arterial wound by a consultant. The facility had no explanation for the lack of a timely assessment by a Registered Nurse.
Plan Of Correction
Resident 240 has been assessed by a RN and CRNP. Physician has been notified of alterations in skin integrity and all documentation has been updated to include characteristics and type of alteration in skin. All residents' current skin wound records have been reviewed for appropriate documentation of character and/or type of alterations in skin. Residents with wound infections, diabetic ulcers, venous ulcers, arterial ulcers, pressure ulcers, open lesions, surgical wounds, and stage 2 and greater burns will be assessed by an RN, referral to wound CRNP will be completed, and physician will be notified if not done previously. Admission policy and skin wound policies will be updated to include residents with wound infections, diabetic ulcers, venous ulcers, arterial ulcers, pressure ulcers, open lesions, surgical wounds, and stage 2 and greater burns will be assessed by a RN, referral to wound CRNP will be completed, and physician will be notified. All licensed nursing staff will be educated on updated policies and requirements for wound documentation to include character and type of wound. A QA tool has been developed to review 10% of admissions weekly to ensure residents with wound infections, diabetic ulcers, venous ulcers, arterial ulcers, pressure ulcers, open lesions, surgical wounds, and stage 2 and greater burns are assessed by a RN, referral to wound CRNP is completed, and physician is notified. 10% of wound documentation forms will be reviewed weekly to ensure new alterations in skin integrity include documentation of character and type of wound. The Quality Assurance (QA) Coordinator or designee will complete the QA review on a weekly basis and re-educate staff not following policy and procedure. The QA Coordinator will review the completed QA tool monthly and will report any trends or patterns at the quarterly Interdisciplinary Quality Assurance and Quality Performance (QAPI) meeting. The QAPI Committee will review the reports at their quarterly meeting and make recommendations for any deficient patterns identified. They will continue to monitor quarterly until the solutions are sustained for a period of two quarters. Decreasing or elimination of this tool will occur only upon recommendation of the Interdisciplinary QAPI Committee at their quarterly meeting.