Failure to Monitor and Report Skin Changes Leading to Pressure Injury Risk
Penalty
Summary
A deficiency occurred when staff failed to monitor and report changes in a resident's skin condition, specifically redness on the left heel, to the attending physician. The resident, an older male with significant medical history including peripheral vascular disease, diabetes, atherosclerosis, and a partial foot amputation, was identified as being at risk for pressure injuries and was dependent on staff for most activities of daily living. Despite physician orders to apply A&D ointment to the left foot for excessive dryness and to monitor for skin breakdown every shift, staff inconsistently applied the ointment and did not consistently monitor or report changes in the skin condition. The resident reported concerns about developing a pressure ulcer on the heels to both facility staff and the physician, but felt these concerns were not addressed. Observations revealed that heel protector boots, intended as a preventive measure, were not consistently used as ordered. Staff interviews confirmed that the ointment was not applied on the day of observation and that the CNA did not notice or report any redness. When the LVN finally assessed the left heel, a reddened area with a black scab was found, and the resident exhibited pain upon palpation. Facility policy required staff to observe for signs of potential or active pressure injury daily and to notify the physician of any significant changes. However, the lack of timely reporting and intervention for the observed skin changes on the resident's left heel constituted a failure to follow these protocols, resulting in a deficiency related to pressure ulcer prevention and care.