Failure to Properly Assess and Document Skin Impairment
Penalty
Summary
The facility failed to meet professional standards of quality care for a resident identified as Resident 39, who developed a skin impairment. According to the Pennsylvania Professional Nursing Practice Act, nurses are required to exercise sound nursing judgment and participate in the planning, implementing, and evaluating of nursing care. The facility's policy on pressure ulcers mandates that nursing staff assess and document significant risk factors for pressure sores, including a full assessment of any pressure sore. However, a review of Resident 39's care plan and nursing progress notes revealed that an unstageable wound was discovered on the resident's left heel, with a dressing applied that was not dated or initialed, indicating a lack of proper documentation and assessment. The facility's investigation into the incident revealed that the wound dressing was applied without proper documentation, and the person responsible for applying it could not be identified. Interviews with staff, including a licensed nurse and the Director of Nursing (DON), confirmed that the dressing was kept in a locked treatment cart accessible only to nurses. The DON acknowledged that upon identifying the skin impairment, the staff should have assessed the wound, notified the physician, and provided appropriate monitoring and treatment. This deficiency was previously cited in past surveys, indicating a recurring issue with nursing services and clinical record maintenance.
Plan Of Correction
1. Resident R39 wound dressing is dated and physician orders for the wound treatment are being followed. 2. Current residents with wound dressings have been reviewed by the DON or designee to ensure treatments are dated and physician orders for the treatment are in place. 3. Licensed staff will be educated by the DON or designee on wound treatment dressings which cannot be applied on a skin impairment without physician orders. If a skin impairment is identified, the physician will be notified and wound treatment orders will be obtained. 4. Random audits of residents with wound dressings will be completed by the DON or designee weekly x4 to ensure wound dressings are dated and physician orders are followed. The audits will be reported to QAPI committee and the QAPI committee will determine the need for further audits.