Neglect in Wound Care for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by an incident involving a skin tear that was not properly treated. The resident, who had a history of dementia, muscle weakness, and repeated falls, was admitted with a care plan indicating potential for skin integrity impairment. A physician's order required the cleansing and dressing of a skin tear on the resident's right forearm. However, the resident's daughter reported a skin tear near the right elbow to a nurse aide, who applied a bandage without cleansing the wound, as the nurse was unavailable and the aide forgot to inform her. The incident was documented in a facility report, noting a bruise on the resident's head and the untreated skin tear. The Director of Nursing acknowledged awareness of the situation but did not investigate it as neglect. The nurse aide involved provided a statement explaining the circumstances, including the absence of the nurse and the subsequent failure to communicate the issue. This oversight resulted in the resident not receiving the necessary care to prevent potential harm, as required by the facility's policy and state regulations.
Plan Of Correction
The Executive Director of Healthcare Services and Director of Nursing investigated this incident on the evening of the incident. Employee El acknowledged that he placed the bandage on Resident R1's arm and forgot to tell the nurse. The Director of Nursing reviewed the incident with employee El on 12/17/24 and shared that he operated outside of his scope of practice and further failed to report the incident to the nurse. Education and corrective action was issued to Employee El on 12/23/24 to ensure the employee understood his job description and the importance of giving full report to his nurse and the oncoming shift. Resident R1's right elbow is healing properly and there were no negative outcomes as a result of this incident. Employee El was educated on 12/17/24 on appropriate reporting and treatment protocols when a resident health incident occurs. All residents have the potential to be affected by this aberrant practice. The DON/designees will perform a one-time audit of front line team members to ensure they have been educated on timely reporting of incidents involving potential abuse or neglect. The Director of Nursing/designees will observe resident care one time daily five days per week for six weeks. Results of the audits will be presented to the QAPI team for any negative trends and follow up recommendations.