Failure to Prevent Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent skin integrity issues. Resident #37, who was admitted with diagnoses including Type 2 diabetes and unspecified abnormalities of gait and mobility, was not provided with adequate care to prevent the development of skin conditions. The resident's records showed a lack of documentation for turning and repositioning, which are critical interventions for preventing skin breakdown. The Treatment Administration Record for the month in question did not document the care provided, and the Care Plan did not include measures for skin condition prevention. Interviews with facility staff revealed inconsistencies in the documentation and execution of care protocols. The Assistant Director of Nursing acknowledged that weekly skin checks were not performed as ordered, and there was no documentation of care being performed as required. Additionally, the Certified Nursing Assistant and Registered Nurse indicated that there was no designated place in the electronic medical record to document turning and repositioning. The Director of Nursing and an Advanced Registered Nurse Practitioner provided conflicting information about the resident's skin condition, further highlighting the lack of proper documentation and communication within the facility.
Plan Of Correction
Resident #37 orders updated for turning and repositioning every 2 hours as tolerated to allow for CNA documentation and care plan developed and implemented for 100% audit with, for turning and repositioning documentation and care plan development and implementation. Inservice 100% of licensed nurses on turning and repositioning order entry for CNA documentation and care plan development and implementation for DON or designee to audit orders for turning and repositioning to allow documentation by CNAs and care plan development and implementation for 2 times weekly for 30 days, and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.