Failure to Identify and Treat Resident Wounds
Penalty
Summary
The facility failed to properly identify, assess, and treat wounds for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including cellulitis, sepsis, and pressure ulcers, was observed to have several untreated and undocumented wounds during a survey. Despite having a care plan in place to address skin integrity, the staff did not fully assess or document all of the resident's wounds, including a skin tear in the groin and an open area below the buttock, until prompted by the surveyor. During the observation, the registered nurse and certified nursing assistant initially identified and treated pressure ulcers on the resident's sacrum but failed to notice other wounds until they were pointed out by the surveyor. The wound specialist was called multiple times to assess and provide treatment orders for these newly identified wounds. Additionally, the nurse did not follow proper infection control procedures, as they did not change gloves or sanitize hands between treating different wound sites on the resident's ankle. The facility's documentation was incomplete, as the resident's skin and wound evaluations did not reflect all the wounds observed during the survey. The Director of Nurses acknowledged that newly identified wounds should be measured, assessed, and reported, and that proper hand hygiene should be maintained during wound care. The facility's wound policy requires that any new areas identified should be reviewed and assessed within 24 hours, which was not adhered to in this case.