Failure to Identify and Assess Resident's Wound
Penalty
Summary
The facility failed to provide necessary care and services to prevent, identify, and properly assess wounds for a resident with a history of cerebral palsy, malnutrition, and contractures. The deficiency was identified when a surveyor observed a wound care nurse performing treatment on the resident's left foot but failing to inspect the right foot, where an open wound was later discovered. The wound care nurse was unaware of the wound on the right foot, and erroneous measurements were documented once the wound was identified. Interviews with staff revealed a lack of awareness and documentation regarding the resident's right foot wound. A Certified Nursing Assistant (CNA) and a Registered Nurse (RN) assigned to the resident were both unaware of the wound, and the RN had failed to identify it during a skin check assessment conducted the day before the surveyor's observation. The facility's Director of Nursing (DON) confirmed that a facility-wide skin sweep had been conducted, but the wound on the resident's right foot was still not identified. The wound care provider later assessed the wound as a trauma wound, noting it required surgical debridement and specific treatments. The provider suggested the wound could have been caused by friction or trauma, possibly due to the resident's limited mobility and contractures. The investigation concluded that the facility failed to identify and properly assess the wound prior to surveyor intervention, leading to the deficiency.
Plan Of Correction
F684, Quality of Care (1) What corrective action(s) will be accomplished for those residents who found to have been affected by the deficient practice? On resident #3 was immediately assessed by a licensed nurse for any adverse effects related to the alleged deficient practice, none were noted. The Attending Physician and care ARNP were immediately notified, orders for treatment received and treatment initiated on. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. A quality review of current residents' skin was completed by the nurse practitioner/designee to ensure no new skin were noted and required treatment. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. The Assistant Director of Nursing or designee-initiated education for the current licensed nurses on about Comprehensive Skin Assessment and Areas to monitor on the body that are Susceptible to. Newly hired nurses will receive education by the Assistant Director of Nursing or designee related to the following: about Comprehensive Skin Assessment and Areas to Monitor on the Body that are Susceptible to. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Assistant Director of Nursing/Designee to conduct weekly audits of resident's Skin Assessments 2x weekly for 8 weeks, then 1x weekly for 4 weeks, and then random audits x 1 week for 4 weeks to ensure compliance with Care identification and appropriate treatments provided. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until substantial compliance has been met.